Health inspection·December 5, 2019

F 0604 activities and toileting. Level of Harm - Minimal harm or potential for actual harm Observations on 12/02/19 at 3:42 P.M., on 12/03/19 at 2:27 P.M. and 4:33 P.M., on 12/04/19 at 2:22 P.M., and on 12/05/19 at 11:12 A.M. revealed Resident #27 sitting in her Broda chair with her seat belt securely fastened around her waist in the 300 hallway and in the common area outside the 300, 400, and 500 hall nurses' station. Resident #27 was observed to make several attempted to stand up from the chair with the seat belt restricting her from standing. Residents Affected - Few Observation on 12/04/19 at 11:45 A.M. revealed Resident #27 enter the main dining room propelled by a staff member while sitting in her Broda chair and the seat belt securely fastened. At 11:55 A.M. a stated tested nurses aide (STNA) sat beside Resident #27 and assisted her with feeding and drinking. The STNA continued to offer food and drink, as well as provide verbal cues to Resident #27 all while Resident #27's seat belt remained securely fastened around her waist. Interview on 12/04/19 at 12:16 P.M. with STNA #350 verified she usually assists Resident #27 with feeding in the dining room and the days she worked. STNA #350 verified Resident #27's seat belt remained secured throughout the lunch time meal, and stated she was busy doing other things and forgot to release Resident #27's seat belt. Interview on 12/04/19 at 2:04 P.M. with STNA #360 and on 12/04/19 at 3:22 P.M. with Licensed Practical Nurse (LPN) #290 both stated Resident #27's seat belt had recently been implemented because she was having increased falls. Further interview with LPN #290 verified Resident #27's care plan intervention to have her seat belt released with supervised meals. Interview on 12/04/19 at 4:08 P.M. with Registered Nurse (RN) #500 stated Resident #27 had multiple falls and her family was requesting a form of restraint. Interview on 12/05/19 at approximately 11:10 A.M. with Director of Nursing (DON) stated Resident #27 was standing and falling a lot from her chair so she talked with Resident #27's hospice provider and decided a self-releasing seat belt would help to keep her safe. Further interview with DON stated Resident #27 could self-release her seat belt but stated she had not asked her release it this week. Observation on 12/05/19 at 11:25 A.M. revealed Resident #27 sitting in her Broda chair at the entrance to the 300 Hall with her seat belt securely fastened around her waist. DON attempted to ask Resident #27 what was around her waist and if she could release her seat belt. Resident #27 stared blankly back at DON and did not respond verbally or attempt to release her seat belt. Interview on 12/05/19 at 11:32 A.M. with DON verified Resident #27 could not self-release her seat belt and verified it was was a restraint. DON also verified the indication for use for Resident #27's seat belt was documented on the consent form as used for positioning and safety with no further documentation of a medical symptom unrelated to a fall intervention. Review of a facility policy titled, Restraints: Physical Restraint Evaluation, dated August 2014, revealed restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints will be used only if medically necessary, beginning with the least restrictive measures to maintain a resident's well-being. Pertinent charting will include assessment of contributing (risk) factors, and the effects of intervention on the resident. The care plan will also be updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 2 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of self-reported incidents, staff interview and policy review, the facility failed implement their abuse policy when they did not report to the State Survey Agency, the Ohio Department of Health (ODH), an allegation of neglect involving Resident #50. This affected one (Resident #50) of one resident reviewed for abuse. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #50 revealed an admission date of 04/09/15. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, other fracture of upper and lower end of unspecified fibula, subsequent encounter for closed fracture with routine healing, post traumatic seizures, anxiety disorder, major depressive disorder, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, alcoholic cirrhosis, respiratory failure, muscle weakness, flaccid hemiplegia affecting unspecified side and thrombocytopenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/11/19, revealed Resident #50 had severe cognitive impairment and required extensive assistance with two person assist for bed mobility and was total dependence with two person assist for transfers. Review of the x-ray reports, dated 05/21/19, revealed Resident #50 had proximal tibia/fibula fractures with malalignment. Mild soft tissue swelling and joint space narrowing. Review of the progress notes, dated 05/21/19 at 7:00 A.M., revealed Resident #50 had a change in condition. Edema and pain were noted to the right leg, at 8:14 A.M. Resident #50's right knee to foot was swollen with bruising noted on the front and back of the calf just below his knee, the calf was firm to touch, there was no warmth noted, Resident #50 complained of discomfort with movement, physician was updated and asked for a x-ray order. At 9:54 A.M., orders were received for a x-ray, ultrasound of the right leg, check uric acid level and utilize Tylenol for discomfort. At 2:47 P.M., the guardian was notified via phone of fracture to right tibia and fibula and the new orders received from the physician to send Resident #50 to the emergency room (ER). There was no record of the resident having a fall or incident to explain the fractures. At 5:21 P.M., Resident #50 left the facility to go to the ER at 4:00 P.M. via transport company for assessment of findings per physician orders. At 10:47 P.M. Resident #50 arrived back to the facility this evening. resting in bed at this time, and denied pain. At 11:30 P.M. orders were noted for an immobilizer and ice to the right leg. Immobilizer was intact to the right leg, slight movement of foot was noted, digits were warm and pink, continues with two to three plus edema right foot, pedal pulse noted. Analgesic (pain medication) was offered and refused by Resident #50. On 05/20/19 and 05/21/19, the resident's medical record was silent to the reason for a fracture to the right tibia and fibula. Review of the facility's self-reported incidents (SRI) from 05/20/19 through 12/03/19 revealed the facility did not complete an SRI involving an allegation of neglect involving Resident #50, when the DON was notified that a State Tested Nursing Aide transferred the resident by herself and the STNA did not report the resident fell during the transfer on 05/21/19. Interview on 12/04/19 at 11:18 A.M. with the Director of Nursing (DON) stated that on 05/21/19, it was reported to her that there was a fracture in the facility of unknown origin. The DON stated that she came to the facility to initiate an investigation and called all the staff that had any interaction with Resident #50 for the past 24 hours. The DON stated that Resident #50 was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 3 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communicate what happened and said she was in the process of reporting it when State Tested Nurse Aide (STNA) #300 reported to the DON that she heard STNA #310 was taking care of Resident #50 and transferred him by herself and ended up dropping him on the floor. The DON stated that she started to call everyone back and got ahold of more people. STNA #310 had went to the back of the building and got another STNA to help her get Resident #50 up and never told the nurse what had happened. On 05/22/19, the DON said she called STNA #310 into the office with union representation and she was terminated. Subsequent interview on 12/04/19 at 2:00 P.M. with the DON verified she did not file a SRI with ODH because she felt she knew what had occurred with the fall, causing a major injury and why the fracture occurred. The DON verified the facility's policy stated they would report to the Survey Agency an injury of unknown origin immediately. Interview on 12/04/19 at 4:48 P.M. with STNA #300 revealed she reported to the DON on 05/21/19 that she heard Resident #50 was dropped the previous evening on 05/20/19, because she saw another aide who was working in her area, was up front and asked the aide what she was doing up there since she was supposed to be working in the back, and the other aide said she was helping STNA #300 transfer a resident and she asked if she actually helped her and she said no, because STNA #300 had already transferred him by herself and he was on the ground. STNA #300 said she saw the other aide at the end of her shift which would of been approximately 10:00 P.M. STNA #300 said she waited until the next day to report it to the DON, because she was thinking STNA #310 would have already reported it that he had fallen. STNA #300 said she overheard one of the unit managers talking to the DON, wondering why Resident #50 was having so much pain in his left leg, and STNA #300 said to the DON and unit manager, it was because he fell yesterday, and they both said what, acting surprised, and they pulled her into the office and questioned her about the incident. Review of the facility's policy titled Abuse Prohibition, Investigation, And Reporting, revised 07/2019, revealed neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is the policy of this facility to prohibit mistreatment, neglect, and abuse of guests/residents and/or misappropriation of guest/resident property or resources. All allegations involving mistreatment, neglect, or abuse, including injuries of unknown origin source and misappropriation of resident property must be reported immediately to the Administrator. The Administrator is responsible for ensuring that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately reported to the State Agency and other officials in accordance with federal regulations and state guidelines. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the State Agency immediately, but no later than two hours after the allegation is made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 4 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, staff interview, review of facility's self-reported incidents and policy review, the facility failed to report to the State Survey Agency, the Ohio Department of Health (ODH), an allegation on neglect involving Resident #50. This affected one (Resident #50) of one resident reviewed for abuse. The facility census was 96. Findings include: Review of the medical record for Resident #50 revealed an admission date of 04/09/15. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, other fracture of upper and lower end of unspecified fibula, subsequent encounter for closed fracture with routine healing, post traumatic seizures, anxiety disorder, major depressive disorder, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, alcoholic cirrhosis, respiratory failure, muscle weakness, flaccid hemiplegia affecting unspecified side and thrombocytopenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/11/19, revealed Resident #50 had severe cognitive impairment and required extensive assistance with two person assist for bed mobility and was total dependence with two person assist for transfers. Review of the x-ray reports, dated 05/21/19, revealed Resident #50 had proximal tibia/fibula fractures with malalignment. Mild soft tissue swelling and joint space narrowing. Review of the progress notes, dated 05/21/19 at 7:00 A.M., revealed Resident #50 had a change in condition. Edema and pain were noted to the right leg, at 8:14 A.M. Resident #50's right knee to foot was swollen with bruising noted on the front and back of the calf just below his knee, the calf was firm to touch, there was no warmth noted, Resident #50 complained of discomfort with movement, physician was updated and asked for a x-ray order. At 9:54 A.M., orders were received for a x-ray, ultrasound of the right leg, check uric acid level and utilize Tylenol for discomfort. At 2:47 P.M., the guardian was notified via phone of fracture to right tibia and fibula and the new orders received from the physician to send Resident #50 to the emergency room (ER). There was nothing in the medical record explaining a recent fall or incident involving this resident. At 5:21 P.M., Resident #50 left the facility to go to the ER at 4:00 P.M. via transport company for assessment of findings per physician orders. At 10:47 P.M. Resident #50 arrived back to the facility this evening. resting in bed at this time, and denied pain. At 11:30 P.M. orders were noted for an immobilizer and ice to the right leg. Immobilizer was intact to the right leg, slight movement of foot was noted, digits were warm and pink, continues with two to three plus edema right foot, pedal pulse noted. Analgesic (pain medication) was offered and refused by Resident #50. Review of the facility's self-reported incidents (SRI) from 05/20/19 through 12/03/19 revealed the facility did not complete an SRI involving an allegation of neglect involving Resident #50, when the DON was notified that a State Tested Nursing Aide transferred the resident by herself and the STNA did not report the resident fell during the transfer on 05/21/19. Interview on 12/04/19 at 11:18 A.M. with the Director of Nursing (DON) stated that on 05/21/19, it was reported to her that there was a fracture in the facility of unknown origin. The DON stated that she came to the facility to initiate an investigation and called all the staff that had any interaction with Resident #50 for the past 24 hours. The DON stated that Resident #50 was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 5 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communicate what happened and said she was in the process of reporting it when State Tested Nurse Aide (STNA) #300 reported to the DON that she heard STNA #310 was taking care of Resident #50 and transferred him by herself and ended up dropping him on the floor. The DON stated that she started to call everyone back and got ahold of more people. STNA #310 had went to the back of the building and got another STNA to help her get Resident #50 up and never told the nurse what had happened. On 05/22/19, the DON said she called STNA #310 into the office with union representation and she was terminated. Subsequent interview on 12/04/19 at 2:00 P.M. with the DON verified she did not file a SRI with ODH because she felt she knew what had occurred with the fall, causing a major injury and why the fracture occurred. Interview on 12/04/19 at 4:48 P.M. with STNA #300 revealed she reported to the DON on 05/21/19 that she heard Resident #50 was dropped the previous evening on 05/20/19, because she saw another aide who was working in her area, was up front and asked the aide what she was doing up there since she was supposed to be working in the back, and the other aide said she was helping STNA #300 transfer a resident and she asked if she actually helped her and she said no, because STNA #300 had already transferred him by herself and he was on the ground. STNA #300 said she saw the other aide at the end of her shift which would of been approximately 10:00 P.M. STNA #300 said she waited until the next day to report it to the DON, because she was thinking STNA #310 would have already reported it that he had fallen. STNA #300 said she overheard one of the unit managers talking to the DON, wondering why Resident #50 was having so much pain in his left leg, and STNA #300 said to the DON and unit manager, it was because he fell yesterday, and they both said what, acting surprised, and they pulled her into the office and questioned her about the incident. Review of the facility's policy titled Abuse Prohibition, Investigation, And Reporting, revised 07/2019, revealed neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is the policy of this facility to prohibit mistreatment, neglect, and abuse of guests/residents and/or misappropriation of guest/resident property or resources. All allegations involving mistreatment, neglect, or abuse, including injuries of unknown origin source and misappropriation of resident property must be reported immediately to the Administrator. The Administrator is responsible for ensuring that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately reported to the State Agency and other officials in accordance with federal regulations and state guidelines. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the State Agency immediately, but no later than two hours after the allegation is made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 6 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 Based on medical record review, observation, staff interview and policy review, the facility failed to provide personal hygiene for Resident #34. This affected one (Resident #34) of one resident reviewed for activities of daily living (ADL) for dependent residents. The facility identified 94 residents that require assistance with ADLs. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #34, revealed an admission date of 06/29/19. Diagnoses included muscle weakness, type two diabetes mellitus without complications, dementia without behavioral disturbance, anxiety disorder and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/19, revealed Resident #34 had severe cognitive impairment and required extensive assistance with two person staff assistance for personal hygiene. Observation on 12/02/19 at 10:13 A.M. revealed Resident #34 sitting in her wheelchair in the 100 hall with long chin hair on her chin. Subsequent observations on 12/03/19 at 12:07 P.M. and 2:44 P.M. revealed Resident #34 sitting in the dining room eating lunch, with long hair on her chin. Observation and interview on 12/04/19 at 9:37 A.M. with Licensed Practical Nurse (LPN) #200 verified Resident #34 had long chin hairs present and she would take care of it for her. Review of the facility's policy titled Guest Care General Guidelines, dated 03/2005, revealed nursing policies and procedures address the total nursing needs of the guests and include at least the following, keeping guests clean, comfortable and well-groomed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 7 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the hospital report, review of the written statements, review of the employee education, review of an employee personnel file, and review of the facility ' s audits, the facility failed to safely transfer a resident as care planned. This resulted in actual harm when Resident #50 suffered a fractured tibia and fibula following an improper transfer by facility staff. This affected one (#50) of one resident reviewed for accidents. The facility census was 96. Findings include: Review of Resident #50's medical record revealed an admission date of 04/09/15. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, other fracture of upper and lower end of unspecified fibula, subsequent encounter for closed fracture with routine healing, post traumatic seizures, anxiety disorder, major depressive disorder, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, muscle weakness, flaccid hemiplegia affecting unspecified side and thrombocytopenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/11/19, revealed Resident #50 had severe cognitive impairment. Resident #50 required an extensive two person assist for bed mobility and was totally dependent with a two person assist for transfers. Review of the care plan, dated 01/21/19, revealed Resident #50 had an Activities of Daily Living (ADL) self-care performance deficit and required assistance with ADLs and mobility related to a traumatic brain injury, aphasia and hemiplegia. Intervention included the resident required dependent assistance with transfers with two staff assistance and a mechanical lift. Review of an undated nursing care card revealed Resident #50 was dependent on staff for transfers and required a two person assist with a mechanical lift. Review of a progress note, dated 05/21/19 at 7:00 A.M., revealed Resident #50 had a change in condition. Further review of the progress notes revealed on 05/21/19 at 8:14 A.M., Resident #50's right leg was edematous with pain noted. Resident #50's right knee to the foot was swollen with bruising noted on the front and back of the calf just below the knee. Resident #50's calf was firm to the touch, with no warmth noted, and Resident #50 complained of discomfort with movement. The progress note dated 05/21/19 at 9:54 A.M., revealed physician orders were received for an x-ray and ultrasound of Resident #50's right leg. Review of the radiology report, dated 05/21/19, revealed a proximal tibia and fibula (bones of the lower leg) fracture with malalignment, mild soft tissue swelling, and joint space narrowing. Review of a progress note, dated 05/21/19 at 2:47 P.M., revealed Resident #50's guardian was notified of the tibia and fibula fractures and informed Resident #50 was sent to the emergency room. Review of an emergency room provider progress note revealed Resident #50 presented with leg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 8 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 swelling and was sent to the emergency room for an evaluation following an x-ray that revealed a fracture of the right tibia and fibula. The progress notes further revealed the emergency room was initially told there was no history of trauma or injury, but later were told there was a possibility of a nurse aide transferring Resident #50 without a mechanical lift, but details were unclear. Residents Affected - Few Interview on 12/04/19 at 9:30 A.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #50 needed a two person assist with a mechanical lift for transfers. LPN #200 verified it was the policy of the facility that two staff members be present when using the mechanical lift. Review of a hand-written note, dated 05/21/19 at approximately 5:00 P.M., revealed a State Tested Nurse Aide (STNA #300) reported to the Director of Nursing (DON) that she heard another STNA (#310) transferred Resident #50 by herself and Resident #50 fell. Review of STNA #310's personnel file revealed an employee disciplinary record document, dated 05/22/19, and indicated STNA #310 transferred a resident (#50) with one assist that was care planned for a two person assist and a mechanical lift. This action resulted in Resident #50 sustaining a fractured leg. STNA #310 was terminated from employment as a result. Interview on 12/04/19 at 11:18 A.M. with the DON stated on 05/21/19, it was reported to her there was a fracture in the facility of unknown origin. The DON stated she came to the facility to initiate an investigation and called all the staff that had any interaction with Resident #50 for the past 24 hours. The DON stated Resident #50 was unable to communicate what happened and said STNA #300 reported to her that STNA #310 was taking care of Resident #50 and transferred him by herself and dropped Resident #50 to the floor. The DON stated she was told STNA #310 got another STNA to help her get Resident #50 up and never told the nurse what happened. The DON stated on 05/22/19, STNA #310 was terminated from employment at the facility. Interview on 12/04/19 at 4:48 P.M. with STNA #300 revealed she reported to the DON on 05/21/19 she heard Resident #50 was dropped the previous evening. STNA #300 stated she saw another aide, who was not working in her area, and the other aide told her she was helping STNA #310 transfer Resident #50. STNA #300 asked the nurse aide if she actually assisted with the transfer, and the nurse aide denied assisting STNA #310 stating Resident #50 was already on the ground because STNA #310 transferred him by herself. As a result of the incident, the facility took the following action to correct the deficient practice by 06/13/19: 1. On 05/21/19, the facility interviewed 19 staff members who provided care for Resident #50, and during the interviews it was discovered Resident #50 was transferred by one staff member (STNA #310). 2. On 05/22/19, STNA #310 was terminated from employment as a result of not following Resident #50 ' s care card intervention to utilize two staff members when performing a mechanical lift transfer which resulted in a fractured leg. 3. On 05/31/19, all staff members were educated on utilizing a two person assist for transfers when there were care plan interventions for a two person assist with transfers. Staff were also instructed that an assessment must be completed for the resident before the resident can be moved after a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 9 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 4. The facility completed audits of three resident transfers each day on 05/23/19, 05/27/19, 05/29/19, 05/31/19, 06/03/19, 06/05/19, 06/07/19, 06/09/19, 06/13/19, 06/14/19, 06/16/19, 06/19/19, and 06/21/19. All transfers were completed using the appropriate level of assistance with no resident injuries noted. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 10 of 11 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 365389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Defiance The 1701 S Jefferson Ave Defiance, OH 43512 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and policy review, the facility failed to provide documentation of monitoring and rationale for continued use of a prophylactic antibiotic for a resident. This affected one (Resident #58) of two residents reviewed for antibiotic stewardship. The facility identified two residents that received prophylactic antibiotics. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #58 revealed an admission date of 10/04/15. Diagnoses included chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/15/19, revealed Resident #58 had severe cognitive impairment and received antibiotics during the seven days of the assessment reference date. Review of the current physician orders revealed an order for trimethoprim (antibiotic) 100 milligrams once daily, with no end date. Interview on 12/04/19 at 7:41 A.M. with Registered Nurse (RN) #510 infection control nurse revealed there were two residents on prophylactic antibiotics. RN #510 verified there was no documentation for the rationale of the continued use of antibiotics. Interview on 12/05/19 at 11:54 A.M. with the Director of Nursing (DON) verified that facility did not have documentation for justification of antibiotic long term use for Resident #58 prior to interview with the infection control nurse. Review of the policy titled Antibiotic Stewardship, dated 05/2016, revealed the facility is committed to improving the use of antibiotics to optimize the treatment of infections while reducing the danger of antibiotic resistance. Physician orders for antibiotics must indicate the dose, duration, and indication for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 11 of 11