Inspection·March 17, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm with other health care providers as well as the practitioner's orders and any diagnostic test results. Record communication with the resident's family. Document teaching provided to the resident and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 2 of 15 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 03/17/2022 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview, the facility failed to ensure residents were without unneeded restrictive devices/physical restraints. This affected six (Residents #7, #25, #27, #29, #44, and #65) of nine residents reviewed for physical restraints. The facility census was 89. Residents Affected - Some Findings include: 1. Review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/03/22, revealed Resident #7 had no behaviors exhibited, not deemed a wanderer, and had a wanderguard placed. Review of the current physician orders dated 03/2022, revealed Resident #7 had an order for a wanderguard for wandering. Review of the Nursing Comprehensive Evaluation (section J), dated 12/27/21, revealed Resident #7 had a total score of eight, which indicated she was not a risk for elopement. 2. Review of Resident #25's medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included dementia and anxiety disorder. Review of the quarterly MDS assessment, dated 01/01/22, revealed Resident #25 had no behaviors exhibited, not deemed a wanderer, and had a wanderguard placed. Review of the current physician orders, dated 03/2022, revealed Resident #25 had an order for a wanderguard with no justification given. Review of the Nursing Comprehensive Evaluation (section J), dated 02/25/22, revealed Resident #25 had a total score of eight, which indicated he was not a risk for elopement. 3. Review of Resident #27's medical record revealed revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and schizophrenia. Review of the quarterly MDS assessment, dated 01/02/22, revealed Resident #27 had no behaviors exhibited, not deemed a wanderer, and had a wanderguard placed. Review of the current physician orders, dated 03/2022, revealed Resident #27 had an order for a wanderguard with no justification given. Review of the Nursing Comprehensive Evaluation (section J), dated 02/17/22, revealed Resident #27 had a total score of eight, which indicated he was not a risk for elopement. 4. Review of Resident #29's medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Parkinson's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 3 of 15 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 03/17/2022 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS assessment, dated 01/03/22, revealed Resident #29 had physical behaviors and exit seeking behaviors one to three days during the time of the assessment; no other behaviors were documented. He was not deemed a wanderer and he had a wanderguard placed. Review of the current physician orders, dated 03/2022, revealed Resident #29 had an order for a wanderguard and no justification given. 5. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, and anxiety disorder. Review of the quarterly MDS assessment, dated 01/18/22, revealed Resident #44 had no behaviors exhibited, not deemed a wanderer, and had a wanderguard placed. Review of the current physician orders, dated 03/2022, revealed Resident #44 had an order for a wanderguard for preventative. Review of the Risk for Elopement assessment, dated 01/07/22, revealed;ed Resident #44 had a total score of five, which indicated she was not a risk for elopement. 6. Review of Resident #65's medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, anxiety disorder, and dementia. Review of the quarterly MDS assessment, dated 02/04/22, revealed Resident #65 was not deemed a wanderer, she had a wanderguard placed, and no behaviors were listed. Review of the current physician orders, dated 03/2022, revealed she had a wanderguard place for precaution for safety. Review of the Nursing Quarterly comprehensive assessment, section J (Elopement), dated 02/18/22, revealed Resident #65 had a score of nine, which indicated no risk for elopement. Observations on 03/16/22 from 3:15 P.M. to 3:30 P.M. revealed the only wanderguard system was located at the front entrance door. The exterior doors to the building were alarmed with 15 second alarms, but no wanderguard system. The interior doors to go in/out of the secured unit did not have a wanderguard system on it as well. Residents #7, #25, #27, #29, #44, and #65 were observed to have a wanderguard and resided on the secured unit. Interviews with Registered Nurse (RN) #510 and the Administrator on 03/15/22 at 11:15 A.M. revealed they have wanderguards on residents in the secured unit because at another sister facility, a resident in the secured unit got out from an exterior door of the building and off the secured unit. This occurred because they walked out of the secured unit with a visitor. So, they placed a wanderguard on residents who families have requested to have one, or those that have a higher likelihood of leaving the secured unit with a visitor. They both confirmed the nine residents with a wanderguard were on the locked/secured unit already, the doors were locked at all times. To unlock the doors to go or off the secured unit, a person must enter a code. Interview with Licensed Practical Nurse (LPN) #401 on 03/17/22 at 10:31 A.M. confirmed there was no wanderguard systems on the exit doors of the secured/locked unit, as well as the other exterior doors, which were locked but can be opened after pushing on the door for 15 seconds. LPN #401 confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 4 of 15 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 03/17/2022 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 0604 Level of Harm - Minimal harm or potential for actual harm the only door that has the wanderguard system was the front, exterior door. She confirmed the wanderguard system doesn't really provide more security for any other door than the front door, but they were trying to prevent someone from leaving the facility. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 5 of 15 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 03/17/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interviews, the facility failed to timely provide hygiene care for a resident who required assistance with activities of daily living (ADL). This affected one (Resident #13) of six residents reviewed for ADLs. The facility identified 87 residents who required assistance with one or more ADLs. The facility census was 89. Residents Affected - Few Findings include: Review of Resident #13's medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included senile degeneration of the brain, diabetes type II, glaucoma, and history of transient ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had cognitive impairment. The resident required extensive assistance of one person for personal hygiene and one person assist for bathing. Review of the care plan dated 01/22/22 revealed Resident #13 had self care performance deficit related to ADL. Resident #13 required assistance with ADLs and mobility related to confusion, weakness, and impaired mobility. Interventions included to keep finger nails trimmed and clean. Review of the ADL care sheet from 02/15/22 to 03/16/22 for Resident #13 revealed shaving and nail care was evaluated and completed as needed every shift. Interview on 03/14/22 at 10:08 A.M. with Resident #13 stated he was not shaved and he needed his fingernails trimmed and cleaned, and he would like to be shaved and have fingernails trimmed. Observations on 03/14/22, 03/15/22, and 03/16/22 revealed Resident #13 had facial hair. The resident's fingernails were past the residents fingertips and had a dark substance under the nails. Interview on 03/16/22 at 8:06 A.M. with State Tested Nursing Assistant (STNA) #348 revealed hospice usually provided the care for Resident #13. STNA #348 verified Resident #13 had not been shaved and fingernails were not trimmed and not clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 6 of 15 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 03/17/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, and staff interviews, the facility failed to ensure geri-sleeves (a cloth covering used to help protect thin skin from tears, abrasions, and light bruising) were in place for three (#29, 36, and #59) of seven residents identified as using geri sleeves. The facility census was 89. Residents Affected - Few Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, Parkinson's disease, cerebral infarction, and muscle wasting. Review of the physician's orders dated 09/10/20 revealed Resident #29 has an order for geri-sleeves daily. Review of Resident #29's Treatment Administration Record (TAR) revealed the staff were initialing the treatment administration record daily indicating geri-sleeves were in place daily. The TAR and medical record were reviewed and silent to Resident #29 refusing to wear the geri sleeves. Observation of Resident #29 on 03/15/22 at 12:05 P.M. in the dining room, waiting at the table for his lunch, revealed the resident was dressed in clean clothes but no geri sleeves were in place. Subsequent observation on 03/15/22 at 2:07 P.M. revealed Resident #29 was ambulating in the dining room and Resident #29 was observed to not have geri sleeves in place. Interview with State Tested Nursing Aide (STNA) #337 on 03/15/22 at 2:07 P.M. confirmed Resident #29 was not wearing his geri-sleeves. On 03/15/22 at 2:08 P.M., Licensed Practical Nurse (LPN) #326 told STNA #337 to go get the resident some geri-sleeves, that possibly there were some in the laundry. During an interview with LPN #326 on 03/15/22 at 2:15 P.M. revealed Resident #29 does not usually have any behaviors or mood that was adversarial. The LPN stated if the resident did have behaviors or was agitated he/she would re-direct the resident and if the change persisted he/she would call the provider, family and the instance as well as provider and family notification would be documented in the progress notes. 2. Review of the medical record for Resident #36 revealed an admission date of 01/20/21. Diagnoses included dementia without behavioral disturbances, compression fracture of the T 11 and T 12 vertebra, contracture of the right and left knee, stiffness of joints, and muscle wasting and atrophy. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 had moderately impaired cognition. Resident #36 required assistance from one staff member for dressing and personal hygiene. Review of Resident #36's physician orders for March 2022 revealed an order for a Geri-sleeve to be applied to Resident #36's left arm every shift for preventative. Review of the plan of care dated 10/26/21 revealed Resident #36 was at risk for impaired skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 7 of 15 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 03/17/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm integrity/pressure injury related to fragile skin. Interventions include to ensure Geri-sleeves were in place as ordered. Observations on 03/14/22 at 9:45 A.M., on 03/15/22 at 10:31 A.M., on 03/16/22 at 1:10 P.M. and 2:45 P.M., and on 03/17/22 at 11:45 A.M. revealed a Geri-Sleeve was not on Resident #36's arm. Residents Affected - Few Interview on 03/17/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #401 confirmed Resident #36 had a physician order for a Geri-sleeve to be placed on the resident's left arm and confirmed Resident #36 did not have a Geri-sleeve on her left arm. 3. Review of the medical record for Resident #59 revealed an admission date of 05/05/14. Diagnoses included diffuse traumatic brain injury, epilepsy, dementia with behavioral disturbance, anxiety, Parkinson's disease, contracture of the right ankle and the left ankle. Review of Resident #59's Braden Scale score, dated 02/03/22, revealed Resident #59 scored a 12.0, indicating the resident was at a high risk for a pressure ulcer. Review of Resident #59's physician orders, dated 06/25/18, revealed an order for Geri sleeves to bilateral arms every day, every shift, for skin protection. Review of Resident #59's care plan, last review date of 02/09/22, revealed an intervention for Geri sleeves to bilateral arms as ordered, initiated date of 01/16/20, due to a risk for impaired skin integrity/pressure injury. Observations of Resident #59 on 03/14/22 at 9:55 A.M. and 11:40 A.M., 03/15/22 at 8:10 A.M., 10:44 A.M. and 11:59 A.M. revealed Geri sleeves were not on Resident #59's bilateral arms. Interview with STNA #334 on 03/15/22 at 12:30 P.M. confirmed the absence of Geri sleeves on Resident #59's bilateral arms. Interview with LPN #326 on 03/15/22 at 1:32 P.M. confirmed the absence of Geri sleeves on Resident #59's bilateral arms. Subsequent interview with LPN # 325 on 03/15/22 at 2:14 P.M. verified Resident #59's physician orders and confirmed the order for Geri sleeves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 8 of 15 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 03/17/2022 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, revealed the facility failed to ensure Resident #53 and #85 received non-pharmacological interventions for pain prior to administering as needed narcotic pain medication. This affected two (#53 and #85) of two residents reviewed for pain management. The facility identified 26 residents on a pain management program. The facility census was 89. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 08/19/22. Diagnoses included type two diabetes mellitus, chronic kidney disease stage four, and neuromuscular dysfunction of the bladder. Review of the pain management plan of care updated 11/16/21 for Resident #53 revealed no interventions for non-pharmacological interventions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was alert and oriented. Resident #53 had frequent pain rated as six on a zero to ten scale (zero indicated no pain and ten was the most severest pain), and received scheduled and as needed pain medications. Review of the physician orders dated 03/2022 revealed Resident #53 received Tylenol 975 milligrams (mg) by mouth three times daily for pain, and oxymoron hydrochloride five mg by mouth every eight hours as needed (PRN) for pain. There was not an order to attempt non pharmacological interventions prior to administering pain medication. Review of the Medication Administration Record (MAR) dated 03/22 revealed no documentation of non-pharmacological interventions. Review of the nursing progress notes dated 03/01/22 through 03/16/22 revealed Resident #53 received as needed pain medication 34 times. Of the 34 opportunities, five times the nurse provided and documented non-pharmacological interventions. An interview on 03/16/22 at 8:52 A.M. with Licensed Practical Nurse (LPN) #301 revealed the nurse was to provide and document non-pharmacological interventions prior to administering pain medication. An interview on 03/16/22 at 12:35 P.M. with the Director of Nursing (DON) revealed the non-pharmacological interventions would be completed and documented prior to administering pain medication. The DON confirmed Resident #53 did not receive routine non-pharmalogical interventions prior to the administration of PRN narcotic pain medications. 2. Review of the medical record for Resident #85 revealed an admission date of 02/19/22. Diagnoses included necrotizing fasciitis to rectal area, surgical aftercare, colostomy and type two diabetes mellitus. Review of the Medicare five-day admission MDS assessment revealed Resident #85 was alert and oriented. Resident #85 had frequent pain of eight on an eight to ten scale, and received as needed pain medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 9 of 15 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 03/17/2022 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician orders dated 03/22 revealed Resident #85 received oxycodone hydrochloride five mg give two tablets by mouth every eight hours as needed for moderate to severe pain. Review of the MAR dated 03/2022 revealed no documentation of non-pharmacological interventions. Review of the nursing progress notes dated 03/01/22 through 03/16/22 revealed Resident #85 received as needed pain medication 29 times. Of the 29 opportunities, four times the nurse provided and documented non-pharmacological interventions. Review of the pain management plan of care dated 03/03/22 for Resident #85 revealed interventions included non-pharmacological interventions of massage, meditation, relaxation, ice/cold pack, diversional activity, guided imagery, and rest and social interaction. An interview on 03/16/22 at 8:52 A.M. with Licensed Practical Nurse (LPN) #301 revealed the nurse was to provide and document non-pharmacological interventions prior to administering pain medication. An interview on 03/16/22 at 12:35 P.M. with the Director of Nursing (DON) revealed the non-pharmacological interventions would be completed and documented prior to administering pain medication. The DON confirmed Resident #85 did not receive routine non-pharmalogical interventions prior to the administration of PRN narcotic pain medications. Review of the facility's policy titled Pain Management, dated 07/09/21, revealed individualized interventions related to the control of pain should include both pharmacological and non-pharmacological interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 10 of 15 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 03/17/2022 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to administer medication as physician ordered to one (#76) of five residents reviewed for unnecessary medications. This had the potential to affect all 89 residents at the facility who were identified to receive medications from the facility staff. Findings include: Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, heart failure, chronic kidney disease, hypertensive heart disease, and chronic obstructive pulmonary disease. Review of Resident #76's care plan dated 06/19/20 revealed the resident had a care plan in place for cardiac complications related to multiple cardiovascular diseases hypertension, hyperlipidemia, and heart failure. Interventions included to administer medications per order. Review of the progress notes dated 03/09/22 revealed Resident #76 was seen by Nurse Practitioner #500 and noted to have two pitting edema in the lower extremities. The plan would be to increase the Lasix (diuretic medication) 40 milligrams (mg) to twice daily from the current once daily dose of Lasix 40 mg. Resident #76 would now be receiving a total of 80 mg of Lasix daily. Review of the medication administration record (MAR) for Resident #76 revealed Resident #76 received only one dose of Lasix 40 mg on 03/09/22, and did not receive the additional dose ordered by the nurse practitioner. The MAR also revealed Resident #76 did not receive any Lasix on 03/10/22 and 03/11/22. Review of the facility's Emergency Drug Kit listing of medications available medications list revealed the kit contained 10 doses of Lasix 40 mg pills. Interview with Licensed Practical Nurse (LPN) #401 on 03/15/22 at 4:25 P.M. verified Resident #76 had no documentation present to indicate Resident #76 received Lasix 40 mg as ordered twice daily on 03/09/22. The LPN also verified the documentation was silent to Resident #76 receiving Lasix on 03/10/22 and 03/11/22 as physician ordered. LPN #401 verified Resident #76 was out of his/her Lasix medication supply and the emergency drug kit had Lasix 40 mg available for the staff to use to provide to the resident. Interview on 03/15/22 at 4:35 P.M. with the Administrator and Registered Nurse (RN) #510 verified the Lasix was not administered to Resident #76 as ordered on 03/09/22, 03/10/22, and 03/11/22. The Administrator and RN #510 verified there were no mention of the missed Lasix doses on 03/09/22, 03/10/22, and 03/11/22 in Resident #76's progress notes. Interview with LPN #309 on 03/16/22 at 12:05 P.M. stated if a medication was not administered and there was no progress note written or note made regarding the medication not being administered, the computer turns the electronic mediation administration record (eMAR) tile for the specific medication in the resident's medication listing red in color, indicating the medication administration is out of compliance. LPN #309 verified the tile for that medication will remain red until the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 11 of 15 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 03/17/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is administered to the resident in the correct time frame, and any staff providing medication to the resident would be able to see the red tile indicating the medication administration was out of compliance. Review of the policy titled Medication Administration, last revised on 12/16/21, revealed the resident medications are administered in an accurate, safe, timely and sanitary manner. Medications are administered in accordance with written orders of the attending physician. Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. Event ID: Facility ID: 365256 If continuation sheet Page 12 of 15 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 03/17/2022 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide the proper food texture to a resident. This affected one (Resident #62) of six residents reviewed for food/nutrition. The facility identified 29 residents who receive a mechanically altered diet. The facility census was 89. Findings include: Review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included dysphagia and dementia. Review of the Minimum Data Set (MDS) assessment, dated 02/24/22, revealed Resident #62 had a severe cognitive impairment. Review of Resident #62's physician orders, dated 03/10/22, revealed a dietary order for mechanical soft diet texture with pureed fruits and vegetables. Observations on 03/16/22 from 11:49 A.M. to 11:51 A.M. revealed the kitchen staff were preparing Resident #62's lunch meal. The tray had a grilled cheese (which was cut into very small pieces by a knife), pureed green beans, and cubed/cooked potatoes. This was placed onto the food cart and taken to the secured unit dining room to be served. Observation on 03/16/22 at 11:56 A.M. revealed Resident #62's meal tray was prepared to be served by facility staff. Observation of Resident #62's meal tray ticket revealed she was to have to have mechanical soft food with puree vegetables and fruit. Her green beans were pureed, but her cubed potatoes were in solid form and not pureed. Interview with Licensed Practical Nurse (LPN) #309 and the Administrator on 03/16/22 at 11:56 A.M. and 12:00 P.M. confirmed Resident #62's meal tray ticket stated she was to have pureed vegetables and confirmed Resident #62 received potatoes in cube/solid form. The Administrator and LPN #309 confirmed that potatoes were deemed to be vegetables. Review of the facility's menu (dated December 2021, week Four, Wednesdays) revealed the following was listed for mechanical soft at lunchtime: three ounces (oz) of ground breaded pork chop, four oz of boiled potatoes, four oz green bean casserole, one dinner roll, and one slice of pumpkin pie. The following was listed for puree texture at lunch time: three oz pureed breaded pork chop, four oz pureed fried potatoes, four oz pureed green bean casserole, two oz dinner roll, and four oz pureed pumpkin pie. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 13 of 15 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 03/17/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observations, staff interview, and facility policy review, the facility failed to store/date food appropriately and failed to serve food in a sanitary manner. This had the potential to affect 88 of 89 residents who eat food from the kitchen (Resident #4 eats no food by mouth). The facility census was 89. Findings include: 1. Observations of the dry storage room in the facility's kitchen on 03/14/22 between 8:14 A.M. to 8:35 A.M. revealed there were the following observations: six cans of sauerkraut with handwritten date of 07/13 (no year) on the top of each can, four cans of sauerkraut with handwritten date of 05/18 (no year) on the top of each can, one can of potatoes with the handwritten date of 07/16 (no year) on top of the can, and three cans of olives with the handwritten date of 08/30/21 on top of each can. Each of the three olive cans also had the expiration date of 02/14/22 on them. Interview with Dietary Manager #353 on 03/16/22 at 11:25 A.M. confirmed she contacted the food supplier. Food supplier confirmed there should have been an expiration date on the food/cans, when there was not. She stated she was putting a new policy in place to put the date on the can when it was received, verify there is an expiration/used by date, and will get rid of the cans if not used within six months. Review of the facility's policy titled Food Purchasing and Storage, dated 11/11/21, revealed it is the policy of the facility to receive, store, and efficiently issue foods, nonfood items, and supplies; to establish receiving methods that ensure all items ordered are received, and to ensure no items are lost, stolen, or allowed to deteriorate. The stock will be rotated when stored. All food items will be dated with the In-Date (dated of delivery). Canned goods and other products will be stocked using the First-In, First-Out method. This means all items already on the shelf are brought to the front of the shelf and new items are stored behind them, which ensures that the older items are used first. 2. Observations on 03/16/22 from 11:33 A.M. to 11:49 A.M. revealed the following information: at 11:33 A.M., Dietary [NAME] #412 was taking the temperature of brown gravy when his gloved hand was placed in the gravy. After taking the temperature, he wiped off his glove with a clean rag; he did not change his gloves. At 11:40 A.M., Dietary [NAME] #412 held a breaded pork chop with his gloved hand as he was cutting it with a knife; he did not change his gloves. At 11:42 A.M., Dietary [NAME] #412 wiped gravy off an already served plate with his gloved hand and then wiped the gravy off his gloved hand onto his soiled shirt; he did not change his gloves. At 11:45 A.M., Dietary [NAME] #412 used his gloved hand to push a piece of breaded pork from the side of the plate to the middle of the plate; he did not change his gloves. At 11:48 A.M., Dietary [NAME] #412 grabbed a hamburger from the metal pan on the steam table with his gloved hand and placed it on a plate; he did not change his gloves. Finally, at 11:49 A.M., Dietary [NAME] #412 held a cooked grilled cheese sandwich with his gloved hand and cut it with a knife; he did not change his gloves. Other items that were touched with Dietary [NAME] #412 gloved hands without changing them (in between touching the food items) included the soiled steam table counter, serving utensils, plates, the plate warming device, his shirt, and the knife used to cut the food items. Interview with Dietary [NAME] #412 and Dietary Manager #353 on 03/16/22 at 11:50 A.M. confirmed he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 14 of 15 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 03/17/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many had not changed his gloves during the time that he took the food temperatures and serving the meals. Dietary [NAME] #412 confirmed all the items that he had touched without changing his gloves. Dietary Manager #353 also confirmed that gloves were to be changed after each new task was completed, which would include touching food items. Review of the facility's list of resident's diets revealed Resident #4 was nothing by mouth and did not receive any food from the kitchen. Review of facility's Glove Use policy, dated 11/12/21, revealed it is the policy of this facility that gloves will be worn when handling food to ensure tat bacteria is not transferred from the food handler's hands to the food product being served. Hands will be washed before putting gloves on and after gloves are removed. Gloves will be used whenever handling food directly. Gloves will be changed and hands will be washed after they become soiled or touch a contaminated surface. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 15 of 15