Health inspection·April 17, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unremarkable. The recommendation was for a repeat in one week if clinically warranted or if symptoms persisted or progressed. Review of the facility investigation and SRI #233874 dated 04/11/23 and timed 10:40 A.M. revealed Resident #3 had a bruised middle finger, and the resident stated a State Tested Nurse Assistant (STNA) did it. It stated the resident was located on the memory care unit and she had impaired cognition, and she had diagnoses of insomnia, depression, anxiety, dementia, and iron deficiency anemia with care plans for abnormal bruising/bleeding, confusion, making false accusations, and she throws objects. The resident stated an STNA named Ruby was rough during care, so the resident gave her a middle finger and the aide twisted her finger, then she went to change the residents roommate, and since she tried to help her, the aide also slapped her roommate. The resident's roommate denied being slapped and had no noticeable marks on her face. The investigation stated there were no staff named Ruby or staff that went by that name, an Xray was taken, and the finger was not broken. The physician and family were notified. The STNA assigned to Resident #3 (STNA #104) was suspended pending the investigation. STNA #104 denied any abuse. All staff were interviewed, and skin sweeps were completed on the memory care residents with no concerns. The police were notified and reviewed the investigation, stating to the facility that there was no evidence to determine abuse had occurred, but that the resident's family wanted to press charges. The allegation was unsubstantiated. Review of the time punch card dated 04/10/23 revealed STNA #104 clocked in at 7:03 A.M. and clocked out at 11:00 P.M. and was assigned to Resident #3. Review of the time punch card dated 04/11/23 revealed STNA #104 clocked in at 7:03 A.M. and clocked out at 9:59 A.M. and was assigned to Resident #3. Review of the staff schedules for 04/10/23 revealed STNA #104 was to work on Resident #3's caseload. Interview on 04/17/23 at 12:02 P.M., with STNA #104 revealed she worked with Resident #3 on Monday (04/10/23) and Tuesday (04/11/23) by herself, unless someone else answered a call light if she was on a break or something. She stated on 04/11/23, management staff called her into the office between what she thought was around 11 o'clock or 12:30 P.M., and she was asked if she abused anyone, she was told there was a complaint that someone hit her (resident #3's) hand, and they made STNA #104 go home. She stated she did not know Resident #3 had any issues with her hand on 04/10/23 when she worked with her. STNA #104 stated Resident #3 can go from a good mood to a bad mood very quickly and she is cognitively impaired. She stated the resident will get mad and will throw coffee at people, call them derogatory names, but she knows how to work with her, and she has never grabbed her finger and the resident had never stuck her finger up at her. Interview on 04/17/23 at 8:36 A.M., with Licensed Practical Nurse (LPN) #103 revealed he went into Resident #3's room to give medications and Resident #3 asked him to check her right middle finger, it was bruised, and she said she gave an aide the middle finger and the aide grabbed it. He immediately called another nurse (LPN #102) and she saw it was bruised too, so they told Assistant Director of Nursing (ADON) #106 and the doctor. The doctor ordered an X-ray, and they did two views of the hand, but the Xray revealed there was no break, and the physician was notified. LPN #103 stated the physician then ordered a Multi-view Xray, but he was unsure if that was done. LPN #103 stated Resident #3 stated someone named Ruth broke her finger, but there was no one there named Ruth and the resident was thinking that whoever did it was lying about their name. LPN #103 stated he was unsure how STNA #104 interacted with the residents because he was typically night shift but happened to be working the day shift that day, and STNA #104 works days. He stated he had no abuse or neglect concerns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 2 of 6 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 04/17/2023 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 0609 other than that one allegation. Level of Harm - Minimal harm or potential for actual harm Interview on 04/17/23 at 2:31 P.M., with LPN #102 revealed LPN #103 had called her to look at Resident #3's finger on 04/10/23, sometime after lunch. She stated the resident did not seem agitated, but she asked LPN #103 to report it and the physician was inhouse and was notified. She stated Resident #3's roommates (Resident #5 and #6) did not seem like anything was off and they did not have any obvious signs of abuse. Residents Affected - Some Interview on 04/17/23 at 2:53 P.M., with ADON #106 and Registered Nurse (RN) Regional Clinical Coordinator #107 revealed ADON #106 stated LPN #103 came to her on 04/10/23 around 5:30 P.M. and told her he thought an aide hurt Resident #3's finger. She went to see Resident #3 and when asked who it did, the resident stated, it was just one of the girls and she did not know a name at first, but then she said Ruby. ADON #106 stated the doctor in house and notified. They ordered Xray's and they notified Resident #3's family. When Resident #3 was asked exactly what happened, she stated someone was changing her and the girl was rough, so the resident stuck her finger up at her, so the girl grabbed it, and when asked about it, it was agitating the resident. She stated it seemed like she could not answer the questions and it was upsetting her. She denied any pain at the time, but then she was offered ice and she refused ice. ADON #106 and RN #107 both confirmed STNA #104 was not removed immediately because the incident was not relayed to the Administrator until that following day (04/11/23). Review of the Employee Disciplinary Record dated 04/11/23, revealed ADON #106 received a written education, that on 04/10/23 at 6:00 P.M. she did not notify the appropriate party (Director of Nursing or Administrator) of an allegation towards a staff member. Interview 04/17/23 at 3:01 P.M., with the Administrator revealed the facility has completed abuse and reporting in services that started right after the incident was reported, he thinks it was initiated on 04/12/23. He stated ADON #106 is new to long term care. The Administrator stated he has been giving his phone number to everyone so they can call him for anything, he even posted it at the nurses station for staff to call him. During their risk meetings, they are looking at Point Click Care (PCC) documentation daily to see if there is anything documented that needs follow up, and if its not addressed or reported, the staff is educated individually. He stated if something was not documented in PCC, he has told the nurses to report to him any concerns. He stated he has new management, and they are going to do skin sweeps to verify nothing else is happening and they also have Angel Rounds where their department heads have specific assigned residents, and they are asked a few times a week if there are issues and if everything is okay. Review of the policy titled Abuse Prohibition Policy, dated 09/09/22, revealed allegations of abuse must be immediately reported to the Administrator. It also stated if the accused perpetrator is an employee of the facility, they will be suspended until the investigation has been completed. This deficiency represents non-compliance investigated under Complaint Number OH00142023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 3 of 6 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 04/17/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of self-reported incidents (SRI), medical record review, staff interviews, and policy review, the facility failed to ensure protection of a resident was provided when a resident alleged physical abuse. This affected one (#3) out of three residents reviewed for abuse. This potentially could affect 12 (#3, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16) assigned to the alleged staff member. The census was 90. Residents Affected - Some Findings include: Review of the medical record for Resident #3 revealed an admission date of 03/11/23 for a respite stay, and a discharge date of 04/14/23 to a hospital per the resident's son request. Diagnoses included dementia, moderate behavioral disturbance, mood disturbances, anxiety, and psychotic disturbance, insomnia, muscle wasting atrophy, recurrent depressive disorders, chronic pain syndrome, and iron deficiency anemias. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/23, revealed Resident #3 had impaired cognition and required extensive assistance of one staff for bed mobility, transfers, toilet use, dressing and personal hygiene and it also indicated the resident had no behaviors, delusions, or hallucinations. Review of the nurse's progress notes revealed on 04/10/23, revealed Resident #3's middle finger was swollen and red, the physician and family were notified, an x-ray (2 views) was ordered to rule out fracture. On 04/11/23, the Xray results revealed there was no fracture noted. The certified nurse practitioner (CNP) was made aware. On 04/12/23, the resident's son was notified there was no fracture. The CNP was in house and ordered another Xray (3 views). The resident son was also notified the resident had stated an employee did it and that an employee was suspended pending the results of the investigation. On 04/12/23, the CNP stated she was asked by staff to see the resident for right middle finger injury. Staff report the injury was caused by a staff member twisting her finger with an investigation and action taken by facility. She is currently lying in bed she reports pain to her right middle finger. She states she cannot move her finger; her ROM is limited. Staff have tried to apply ice, but the patient will not tolerate ice at this time. Her Xray of the finger was negative for acute fracture or dislocation, though she continues to have significant edema and ecchymosis. On 04/12/23 at 6:40 P.M., a police officer arrived and requested to see Resident #3. He stated the resident's son had called the squad and wanted her taken to the hospital for treatment for a fractured hand. Paperwork was prepared for the hospital staff. Review of Resident #3's Xray results dated 04/11/23 revealed there was no acute fracture or dislocation, the osseous structures appear intact, modest joint space narrowing, and soft tissues are unremarkable. The recommendation was for a repeat in one week if clinically warranted or if symptoms persisted or progressed. Review of the facility investigation and SRI #233874 dated 04/11/23 and timed 10:40 A.M. revealed Resident #3 had a bruised middle finger, and the resident stated a State Tested Nurse Assistant (STNA) did it. It stated the resident was located on the memory care unit and she had impaired cognition, and she had diagnoses of insomnia, depression, anxiety, dementia, and iron deficiency anemia with care plans for abnormal bruising/bleeding, confusion, making false accusations, and she throws objects. The resident stated an STNA named Ruby was rough during care, so the resident gave her a middle finger and the aide twisted her finger, then she went to change the residents roommate, and since she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 4 of 6 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 04/17/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tried to help her, the aide also slapped her roommate. The resident's roommate denied being slapped and had no noticeable marks on her face. The investigation stated there were no staff named Ruby or staff that went by that name, an Xray was taken, and the finger was not broken. The physician and family were notified. The STNA assigned to Resident #3 (STNA #104) was suspended pending the investigation. STNA #104 denied any abuse. All staff were interviewed, and skin sweeps were completed on the memory care residents with no concerns. The police were notified and reviewed the investigation, stating to the facility that there was no evidence to determine abuse had occurred, but that the resident's family wanted to press charges. The allegation was unsubstantiated. Review of the time punch card dated 04/10/23 revealed STNA #104 clocked in at 7:03 A.M. and clocked out at 11:00 P.M. and was assigned to Resident #3. Review of the time punch card dated 04/11/23 revealed STNA #104 clocked in at 7:03 A.M. and clocked out at 9:59 A.M. and was assigned to Resident #3. Review of the staff schedules for 04/10/23 revealed STNA #104 was to work on Resident #3's caseload. Interview on 04/17/23 at 12:02 P.M., with STNA #104 revealed she worked with Resident #3 on Monday (04/10/23) and Tuesday (04/11/23) by herself, unless someone else answered a call light if she was on a break or something. She stated on 04/11/23, management staff called her into the office between what she thought was around 11 o'clock or 12:30 P.M., and she was asked if she abused anyone, she was told there was a complaint that someone hit her (resident #3's) hand, and they made STNA #104 go home. She stated she did not know Resident #3 had any issues with her hand on 04/10/23 when she worked with her. STNA #104 stated Resident #3 can go from a good mood to a bad mood very quickly and she is cognitively impaired. She stated the resident will get mad and will throw coffee at people, call them derogatory names, but she knows how to work with her, and she has never grabbed her finger and the resident had never stuck her finger up at her. Interview on 04/17/23 at 8:36 A.M., with Licensed Practical Nurse (LPN) #103 revealed he went into Resident #3's room to give medications and Resident #3 asked him to check her right middle finger, it was bruised, and she said she gave an aide the middle finger and the aide grabbed it. He immediately called another nurse (LPN #102) and she saw it was bruised too, so they told Assistant Director of Nursing (ADON) #106 and the doctor. The doctor ordered an X-ray, and they did two views of the hand, but the Xray revealed there was no break, and the physician was notified. LPN #103 stated the physician then ordered a Multi-view Xray, but he was unsure if that was done. LPN #103 stated Resident #3 stated someone named Ruth broke her finger, but there was no one there named Ruth and the resident was thinking that whoever did it was lying about their name. LPN #103 stated he was unsure how STNA #104 interacted with the residents because he was typically night shift but happened to be working the day shift that day, and STNA #104 works days. He stated he had no abuse or neglect concerns other than that one allegation. Interview on 04/17/23 at 2:31 P.M., with LPN #102 revealed LPN #103 had called her to look at Resident #3's finger on 04/10/23, sometime after lunch. She stated the resident did not seem agitated, but she asked LPN #103 to report it and the physician was inhouse and was notified. She stated Resident #3's roommates (Resident #5 and #6) did not seem like anything was off and they did not have any obvious signs of abuse. Interview on 04/17/23 at 2:53 P.M., with ADON #106 and Registered Nurse (RN) Regional Clinical Coordinator #107 revealed ADON #106 stated LPN #103 came to her on 04/10/23 around 5:30 P.M. and told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 5 of 6 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 04/17/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her he thought an aide hurt Resident #3's finger. She went to see Resident #3 and when asked who it did, the resident stated, it was just one of the girls and she did not know a name at first, but then she said Ruby. ADON #106 stated the doctor in house and notified. They ordered Xray's and they notified Resident #3's family. When Resident #3 was asked exactly what happened, she stated someone was changing her and the girl was rough, so the resident stuck her finger up at her, so the girl grabbed it, and when asked about it, it was agitating the resident. She stated it seemed like she could not answer the questions and it was upsetting her. She denied any pain at the time, but then she was offered ice and she refused ice. ADON #106 and RN #107 both confirmed STNA #104 was not removed immediately because the incident was not relayed to the Administrator until that following day (04/11/23). Review of the Employee Disciplinary Record dated 04/11/23, revealed ADON #106 received a written education, that on 04/10/23 at 6:00 P.M. she did not notify the appropriate party (Director of Nursing or Administrator) of an allegation towards a staff member. Interview 04/17/23 at 3:01 P.M., with the Administrator revealed the facility has completed abuse and reporting in services that started right after the incident was reported, he thinks it was initiated on 04/12/23. He stated ADON #106 is new to long term care. The Administrator stated he has been giving his phone number to everyone so they can call him for anything, he even posted it at the nurses station for staff to call him. During their risk meetings, they are looking at Point Click Care (PCC) documentation daily to see if there is anything documented that needs follow up, and if its not addressed or reported, the staff is educated individually. He stated if something was not documented in PCC, he has told the nurses to report to him any concerns. He stated he has new management, and they are going to do skin sweeps to verify nothing else is happening and they also have Angel Rounds where their department heads have specific assigned residents, and they are asked a few times a week if there are issues and if everything is okay. Review of the policy titled Abuse Prohibition Policy, dated 09/09/22, revealed allegations of abuse must be immediately reported to the Administrator. It also stated if the accused perpetrator is an employee of the facility, they will be suspended until the investigation has been completed. This deficiency represents non-compliance investigated under Complaint Number OH00142023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 6 of 6