Inspection·June 12, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm first incontinence check with Resident #191 since assuming care at 6:00 A.M. CNA #482 removed Resident #191's adult incontinence brief and noted he was incontinent of a large amount of urine. CNA #482 provided perineal care and turned the resident to the left side. Resident #191 buttock was noted to be soiled with urine and tissue appeared slightly red. Both CNA's stated Resident #191 was a, heavy wetter and required frequent incontinence checks. Residents Affected - Few On 06/11/25 at 11:04 A.M. interview with the Director of Nursing verified Resident #191 required two hour incontinence checks. Review of facility Nursing Rounds/Licensed Staff policy revised 02/15/24 revealed to check residents at least every two (2) hours. The routine check involves entering the residents room to determine if the residents needs are being met. If there has been a change in the resident's condition; or if the resident has any complaints. This deficiency represents non-compliance investigated under Complaint Number OH00165101. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 2 of 10 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 06/12/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure tracheostomy care was provided with approved technique to prevent cross contamination. This affected one (#191) of one residents reviewed for tracheostomy care and treatment. Facility census 93. Residents Affected - Few Findings include: Resident #191 admitted to the facility on [DATE] with diagnoses including, chronic obstructive pulmonary disease, hypertension, anxiety disorder, atrial fibrillation, myocardial infarction, type 2 diabetes mellitus, bipolar disorder, panic disorder, malnutrition, coronary artery disease, anemia, peripheral vascular disease, tracheostomy, and gastrostomy. According to the nursing admission assessment dated [DATE] Resident #191 was assessed with impaired cognition, was dependent on staff for the provision of activities of daily living, received nutrition via feeding tube, and was incontinent of bowel and bladder. Review of physician orders revealed Tracheostomy (Trach) care to be performed every shift effective 05/28/25. Trach size 6 flex as needed for trach information effective 05/29/25. Change inner trach cannula as needed to maintain airway effective 05/29/25. Change inner tracheostomy (Trach) cannula size six (6) daily on night shift effective 05/30/25. Change trach ties weekly every night shift on every Saturday for infection control effective 05/31/25. On 06/09/25 a nursing plan of care was revised to address Resident #191 risk for respiratory distress, decannulation, infection related to Tracheostomy. Interventions were as indicated; Ensure that trach ties are secured at all times. Provide tracheostomy care/dressing change per order/facility protocol. Observation on 06/11/25 at 8:54 A.M. noted Licensed Practical Nurse (LPN) #406 at Resident #191 bedside and placed a Tracheostomy care kit on the overbed table. Multiple personal items were observed on the table and LPN #406 did not clean the table prior to the procedure. LPN #406 washed hands and proceeded to open the Tracheostomy kit. LPN #406 removed and donned sterile gloves from the kit and proceeded to open a bottle of saline which was contained inside the sterile kit. LPN #406 proceeded to open a separate individual disposable inner trach cannula. LPN #406 then handled Resident #191 tracheostomy soiled inner cannula and removed the inner cannula placing it to the trash receptacle. Without changing gloves or washing hands, LPN #406 took a cotton tipped applicator and placed the tip to the saline. LPN #406 cleansed the exterior of the remaining trach opening and inserted the tip into the trach opening. LPN #406 then handled the clean inner cannula with the soiled gloves, placed gloved fingers to the clean shaft of the cannula and subsequently into Resident #191 trach stoma. LPN #406 obtained a clean gauze dressing from the trach kit, dipped the dressing into the saline solution, cleansed the trach stoma and applied a clean/dry drain sponge to the stoma. LPN #406 then removed the existing trach ties and replaced with clean/new trach ties. On 06/11/25 at 9:08 A.M. interview with LPN #406 verified cross contamination had occurred during the tracheostomy cleaning procedure. Review of facility Tracheostomy tube cannula and stoma care procedure undated. Preparation of Equipment. Place equipment and supplies on a clean table or stand near the patient's bed. Open the tracheostomy care kit using sterile technique. Using sterile technique, pour sterile normal saline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 3 of 10 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 06/12/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few solution, sterile water, or other cleaning solution into one of the sterile solution containers. Then pour sterile normal saline solution or sterile water into the second sterile container for rinsing. For inner cannula care, you may use a third sterile solution container to hold the sterile gauze pads and sterile cotton-tipped applicators saturated with normal saline solution. If you must replace the disposable inner cannula, open the package containing the new inner cannula. Obtain or prepare new tracheostomy ties, if indicated. Implementation. Perform hand hygiene. Put on gloves and, as needed, other personal protective equipment (PPE). Assess the patient's respiratory status and need for suctioning. Remove the patient's tracheostomy dressing, inspect it for drainage, and then discard it. Remove and discard gloves. Caring for a disposable inner cannula. Perform hand hygiene. Put on clean gloves. Using your dominant hand, remove the patients inner cannula. After evaluating the secretions in the cannula, discard it properly. Pick up the new inner cannula, touching only the outer locking portion. Insert the cannula into the tracheostomy and lock it securely following the manufacturer's instructions. Remove and discard your gloves. Perform hand hygiene. Cleaning stoma and outer cannula. Put on clean gloves. With dominant hand, moisten a gauze pad with normal saline solution or water. The wipe the patients neck under the tracheostomy tube flanges and tracheostomy ties. Assess the stoma site and surrounding skin. Use a cotton tipped applicator and gauze pad to clean the stoma site and the tubes flanges. Wipe only once with each applicator or gauze pad and then discard it to prevent contamination of a clean area with a soiled applicator or pad. Loosen dried secretions with a sterile cotton-tipped applicator or gauze pad. Rinse debris with one or more gauze pads dampened with normal solution or water. Dry area thoroughly with additional gauze pads. Remove the tracheostomy ties and apply new ones. Apply a new tracheostomy dressing. Remove and discard gloves and other PPE. Perform hand hygiene. On 06/11/25 at 9:15 A.M. interview with the Director of Nursing verified LPN #406 did not follow tracheostomy care policy during tracheostomy care and resulted in cross-contamination during the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 4 of 10 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 06/12/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure pharmacy recommendations were responded to in a timely manner. This affected two residents (#48 and #24) of five residents reviewed for unnecessary medications. The census was 93 residents. Findings Include: 1. Review of Resident #48's medical record revealed an admission date of 11/01/21. Diagnoses included dementia with behavioral disturbance, multiple sclerosis, impulsiveness, adjustment disorder with mixed anxiety and depression, and central nervous system disorder. Review of Resident #48's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #48 was moderately cognitively impaired. Resident #48 required maximal assistance with toilet use, bathing, personal hygiene. Resident #48 was independent with bed mobility and required supervision with transfer. Resident #48 displayed no behaviors during the review period. Review of Resident #48's Pharmacy Recommendations revealed on 12/17/24 the pharmacist reviewed Resident #48's Ability 5 milligrams (mg) daily for impulse disorder since 07/16/24, Paroxetine 40 mg daily, and Trazodone 25 mg daily and 100 mg at night, having been increased on 08/15/24. The pharmacist recommended a consideration of a gradual dose reduction, perhaps decreasing to Abilify 2 mg daily or document why a gradual dose reduction was clinically contraindicated. The pharmacist recommendation was not reviewed by the physician until 02/12/25. The physician declined the recommendation. Also reviewed by the pharmacist on 12/17/24 was Resident #48's nicotine patch for smoking cessation. Nicotine 21 mg patch since 08/16/24. Please consider a step down schedule based on the individuals body weight, recent cigarette use and cardiovascular disease. The physician did not review the recommendation until 02/12/25. The physician accepted the recommendation. Interview on 06/11/25 at 7:50 A.M. with the Director of Nursing (DON) verified Resident #48's December 2024 pharmacy recommendations were not reviewed by the physician until February 2025. 2. Review of Resident #24's medical record revealed an admission date of 10/18/24. Diagnoses include dementia, anxiety, type two diabetes mellitus, muscle weakness, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact. Review of Resident #24's monthly pharmacy review revealed the physician reviewed Resident #24's medication omeprazole 20 milligrams (mg) one capsule by mouth once daily. The pharmacy recommended to discontinue famotidine. The date of the recommendation was 12/18/24 and was signed by the physician on 02/12/25. The physician accepted the recommendations with the following modification: stop famotidine and monitor for worsening of reflux symptoms. Interview on 06/11/25 at 7:51 A.M. with the Director of Nursing (DON) verified the recommendation date was 12/18/24 and was not signed by the physician until 02/12/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 5 of 10 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 06/12/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Timeliness of Medication Regimen Review (MRR) Reports, with a last revised date of 09/07/23 revealed the attending physician is expected to review the resident's individual MRR and document and sign that he/she had reviewed the pharmacist's identified recommendations within 14 days of receipt. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 6 of 10 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 06/12/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policy, and pharmacy documentation, the facility failed to store resident insulin in a safe and sanitary manner. This affected six of 17 residents (#14, #24, #25, #31, #34 #51) identified by the facility to receive insulin administration in a facility census of 93. Findings include: 1. Observation on [DATE] at 10:55 A.M. with Licensed Practical Nurse (LPN) #402 during observation of the 100 hall medication cart storage noted three open insulin pens. Resident #25 Fiasp insulin pen, Resident #14 Lantus insulin pen, and Resident #34 Basaglar insulin pen. No date was marked on the insulin pens indicated when they were opened. Interview with LPN #402 at the time of observation verified insulin pens, and vials are to be marked with the date when opened. According to facility pharmacy guidelines for Medications with Shortened Expiration dates indicated Fiasp, Lantus, and Basaglar insulins expire 28 after opening. 2. On [DATE] at 10:59 A.M. observation of the medication storage inside the 200 hall medication cart with LPN #457 discovered Resident #51 Novolog insulin pen open inside the cart. No date was marked on the pen indicating when opened. Interview with LPN #457 at the time of observation verified insulin pens and vials are to be marked with the date when opened. According to facility pharmacy guidelines for Medications with Shortened Expiration dates indicated Novolog insulins expire 28 after opening. 3. Observation with LPN #455 on [DATE] at 11:16 A.M. noted the medications stored inside the 300 hall medication cart. Resident #31 Lispro pen was observed to be dated as opened on [DATE]. A Toujeo pen was open without a name or date open marked on the insulin pen. Resident #24 Novolog insulin vial was marked as opened on [DATE]. An insulin vial containing Fiasp insulin was marked as opened on [DATE] without a resident name indicated on the container. Interview with LPN #455 at the time verified the insulin pens and vials lacking appropriate date marking and expired. According to facility pharmacy guidelines for Medications with Shortened Expiration dates indicated Novolog, Fiasp, Lispro insulin expired 28 days after opening. Toujeo insulin pens expire 42 days after opening. On [DATE] at 8:00 A.M. interview with the Director of Nursing (DON) during review of pharmacy guidelines for medications with shortened expiration dates verified insulins observed were to be discarded after 28 days. Facility identified 17 current residents that received insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 7 of 10 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 06/12/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of facility medication administration, insulin administration policy effective [DATE] revealed to follow the manufacturer's instruction for storage and expiration. Ensure the opened date is documented on the vial or pen. Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded should be discarded. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 8 of 10 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 06/12/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure adequate infection control practices were carried out. This affected three residents (#82, #55, and #303) of five residents reviewed for infection control practices. The facility census was 93. Residents Affected - Few Findings Include: 1. Review of Resident #82's medical record reveals an admission date of 05/13/25 Diagnoses included right femur fracture subsequent encounter, type II diabetes, heart disease, chronic obstructive pulmonary disease (COPD) and clostridium difficile (C-Diff). Review of Resident #82's physician orders revealed an order dated 06/04/25 for oxygen at two liters via nasal cannula to maintain greater than 92% and an order for contact isolation for C-Diff all services provided in room and in room by self. Observation on 06/09/25 at 12:20 P.M. of Resident #82 found her in bed in her room. A sign was posted announcing Resident #82 was on contact precautions. Personal protective equipment including gloves, gowns, and facemasks was available in a cart outside her room. Certified Nursing Assistant (CNA) #477 delivered Resident #82 her breakfast tray and set her food items. Resident #82 requested assistance with adjusting her oxygen tubing. CNA #477 was observed adjusting Resident #82's oxygen tubing in her nose and around her ears. CNA #477 did not don gloves when she came in contact with Resident #82. Interview on 06/09/25 at 12:25 P.M. with CNA #477 verified gloves were available and she should have worn them when she came in physical contact with Resident #82. Review of the facility policy titled, Contact Precautions, revised 10/14/22 revealed health care personnel caring for residents on Contact Precautions should wear gloves and a gown for all interactions that may involve contact with the resident. 2. Review of Resident #55's medical record revealed an admission date of 04/11/25. Diagnoses included hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease, muscle weakness and cerebral infarction. Observation on 06/09/25 at 12:30 P.M. found CNA #482 delivering hall trays to the 400 hall. Observation on 06/09/25 at 12:35 P.M. found CNA #482 lifted her shirt collar with her left hand and coughed into her hand and shirt. CNA #482 did not use hand sanitizer and removed Resident #55's lunch tray from the meal delivery cart. CNA #482 delivered and set up Resident #55's lunch meal. Interview on 06/09/25 at 12:37 P.M. with CNA #482 verified she had not used hand sanitizer before delivering Resident #55's tray but had used the hand sanitizer in the room after setting up the meal. Review of the facility policy titled, Hand Hygiene, revised 05/08/25 revealed hand hygiene should be preformed after contact with body fluids and when contaminated with proteinaceous materials (phlegm or sputum). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 9 of 10 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 06/12/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident #303's medical record revealed an admission date of 06/06/25. Diagnoses include nondisplaced fracture of seventh cervical vertebra, type two diabetes mellitus, history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of Resident #303's physician orders dated 06/06/25 revealed an order for an indwelling urinary catheter. Observation on 06/10/25 at 08:50 A.M. of Resident #303's door and wall outside of the room revealed there was no enhanced barrier precaution sign posted. Interview on 06/10/25 at 08:52 A.M. with Licensed Practical Nurse (LPN) #404 verified an enhanced barrier precaution sign was not present on the door or the wall outside of Resident #303's room. Furthermore LPN #404 verified Resident #303 had an indwelling urinary catheter. Review of the policy titled Enhanced Barrier Precautions (EBP) with a revision date of 03/05/25 revealed to post signage for precautions on the door or wall outside of the residents room indicating the type of precautions and required personal protective equipment (PPE). Furthermore EBP were indicated for residents with indwelling medical devices which included central lines, urinary catheters, feeding tubes, and tracheotomies. This deficiency represents non-compliance investigated under Complaint Number OH00166459 and OH00165186. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365389 If continuation sheet Page 10 of 10