Health inspection·September 16, 2021

F 0644 facility's admission policy. All potential guests of the facility will be evaluated using facility specific tools as well as the Pre-admission Form (PASARR) for mental illness, mental retardation, or related conditions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 2 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 medical record review, observation, resident interview, staff interview, and facility policy and procedure, the facility failed to complete showers per resident preference and complete nail care as needed. This affected five (#34, #35, #43, #76, and #80) out of five residents reviewed for activities of daily living (ADL's). Residents Affected - Some Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) Assessment, dated 07/12/21, revealed the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive assistance of one staff for personal hygiene, and limited assistance of one staff for locomotion via wheelchair. Review of the care plan dated 03/24/21 revealed the resident had an ADL self care performance deficit and required assistance with ADL's and mobility related to activity intolerance, fatigue, weakness, impaired balance, pain, shortness of breath and diagnoses. Interventions included extensive staff assistance for personal hygiene and bathing, she had a preference for showers, and showers were on Mondays, Wednesdays, Fridays, and as needed. Review of Resident #34's shower documentation for July 2021, August 2021, and September 2021 revealed the following: For July 2021, the resident didn't receive her scheduled showers on 07/07/21, 07/24/21, and 07/28/21. For August 2021, the resident didn't receive showers on 08/04/21, 08/07/21, 08/11/21, 08/14/21, 08/21/21, and 08/25/21. For September 2021, the resident didn't receive showers on 09/01/21, 09/04/21, 09/06/21, and 09/08/21. Interview on 09/13/21 at 10:08 A.M. with Resident #34 revealed she wasn't receiving her showers in general/per her preference due to lack of staff at the facility. Interview on 09/15/21 at 11:50 A.M. with the Director of Nursing (DON) revealed residents shower preferences are documented in the care plan. Interview on 09/15/21 at 12:22 P.M. with the Administrator confirmed the above absence of showers for Resident #34. Review of the facility policy and procedure titled, Tub Baths and Showers, undated, revealed the facility policy was that residents require a minimum of one shower weekly. 2. Review of the medical record for Resident #43 revealed an admission date of 11/14/12. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), other schizoaffective disorders, delusional disorders, bipolar disorder, major depressive disorder, morbid obesity due to excess calories, adult failure to thrive, displaced fracture of the left lower leg, pain in bilateral shoulders, and abnormal posture. Review of the quarterly Minimum Data Set (MDS) assessment on 07/16/21 revealed Resident #43 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 3 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 severely impaired cognition and was totally dependent on staff for assistance with bathing. Level of Harm - Minimal harm or potential for actual harm Review of the Individual Care Service Plan, dated 09/16/21, revealed Resident #43 required total staff assistance from one staff for bathing. The resident should receive a shower two times per week on Wednesdays and Saturdays and as needed (prn). Residents Affected - Some Review of the plan of care, dated 02/28/19, revealed Resident #43 had a self-care performance deficit with completing Activities of Daily Living (ADL's) and required staff assistance. Interventions for bathing included the resident required total staff assistance from one staff person. Showers should be offered two times per week on Wednesdays and Saturdays and prn. Review of shower logs from 08/01/21 through 09/16/21 revealed Resident #43 did not receive a shower as scheduled on 8/14/21, 08/21/21, 09/04/21, 09/08/21, 09/11/21, or 09/15/21. Interview on 09/13/21 at 3:07 P.M. with Resident #43 revealed the resident did not receive showers as scheduled. Interview on 09/15/21 at 12:25 P.M. with the Administrator confirmed Resident #43 had not received showers as scheduled in August and September 2021. The Administrator stated she was looking into the issue but was not sure why the resident had not received showers as scheduled on Wednesdays and Saturdays. 3. Review of the medical record for Resident #76 revealed an admission date on 02/01/19 with medical diagnoses including chronic respiratory failure, unspecified asthma, cerebral infarction (stroke), major depressive disorder, generalized anxiety disorder, chronic viral hepatitis C, hemiplegia and hemiparesis following cerebrovascular disease affecting an unspecified side, generalized weakness, contracture of left knee, and shortness of breath. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/17/21, revealed Resident #76 had intact cognition and required extensive assistance from one to two staff persons to complete Activities of Daily Living (ADL's). The bathing activity itself did not occur during the review period. Review of the plan of care for Resident #76, revised 08/27/21, revealed the resident had a self-care performance deficit with completing ADL's. Interventions included Resident #76 required extensive assistance from one staff person to complete bathing. The resident should be offered showers two times per week on Thursdays and Sundays and as needed (prn). Review of the Individual Care Service Plan for Resident #76, dated 09/16/21, revealed the resident required extensive assistance from one staff person to complete bathing. The resident should be offered showers two times per week on Thursdays and Sundays and as needed. Review of shower logs from 07/01/21 through 09/16/21 revealed Resident #76 was scheduled for showers three times per week on Tuesdays, Thursdays, and Saturdays. The resident did not receive showers as scheduled. The resident missed showers on 07/06/21, 07/13/21, 07/15/21, 07/18/21, 07/25/21, 07/29/21, 08/01/21, 08/03/21, 08/08/21, 08/15/21, 08/17/21, 08/24/21, 08/31/21, 09/02/21, 09/05/21, 09/07/21, or 09/14/21. Interview on 09/13/21 at 2:07 P.M. with Resident #76 revealed the resident only received showers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 4 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when it was convenient for the staff. The resident stated she usually only received a shower once a week and was supposed to receive a shower three times a week on Tuesdays, Thursdays, and Saturdays. The resident stated she received a shower yesterday, 09/12/21, but had not received a shower in an entire week prior to that shower. The resident stated she only wanted a shower and would not accept a bed bath. Interview on 09/15/21 at 9:26 A.M. with Resident #76 revealed she did not receive a shower as scheduled yesterday, 09/14/21. Interview on 09/14/21 at 4:51 P.M. with the Administrator confirmed Resident #76 was scheduled to receive showers three times a week on Tuesdays, Thursdays, and Saturdays. The Administrator confirmed the resident did not receive showers as scheduled in July, August, or September. The Administrator stated she was looking into the issue but had not determined why the resident had not received showers as scheduled. 4. Resident #80 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T11-T12, history of falls, dementia without behavioral disturbance, recurrent major depressive disorder, acute congestive heart failure, shortness of breath and nondisplaced intertrochanteric fracture of right femur. Review of Resident #80's comprehensive MDS assessment, dated 08/19/21, revealed the resident had moderate cognitive impairment and required the extensive assistance of one staff person for dressing and personal hygiene. The bathing activity was marked as not occurring during the assessment period. Review of the Resident #80's individual service care plan indicated she preferred a shower before bed. Interventions included offer showers three times per week on Tuesdays, Thursdays and Saturdays and as needed. Nails were to be trimmed on shower days. She required extensive assistance of one with bathing and staff to provide a sponge bath when a full bath or shower could not be tolerated. Review of the shower documentation from July 2021, revealed Resident #80 only received seven of 13 scheduled showers plus she refused two. August 2021 shower documentation revealed she received six of 13 scheduled showers plus she refused two. September 2021 shower documentation revealed she only received two of six scheduled showers. Interview with Resident #80 on 09/14/21 at 9:27 A.M. revealed she was not consistently receiving showers. She was observed with uncombed hair and long nails. Interview with the administrator on 09/15/21 at 11:30 A.M. reported the provided shower records were the only shower records found. 5. Record review for Resident #35 revealed an admission date of 07/13/21. Diagnosis included adult failure to thrive, difficulty in walking and muscle weakness. Review of Resident #35's Minimum Data Set (MDS) assessment, dated 07/20/21, revealed resident the resident had moderately impaired cognition. The resident required two- person assistance for bed mobility, transfers, and toilet use, extensive assistance of one person for walking in the room, dressing, and personal hygiene. Review of the care plan, dated 07/14/21, revealed the resident had an activities of daily living (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 5 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some self-care performance deficit and required assistance with activities of daily living. Resident #35 required extensive assist of one person to dress and for personal hygiene. Interventions included to check nail length and trim and clean on bath day and as necessary. Record review of the shower sheets revealed resident was scheduled to receive a shower on Mondays and Thursdays. Record review of the shower record for September 2021 revealed resident did not receive a shower or bath on 09/09/21 or 09/13/21. Observation on 09/14/21 at 07:52 A.M. revealed Resident #35 sitting up in his bed eating breakfast. Resident #35's fingernails were approximately ½ to ¾ inch long in length, uneven and partially broken with sharp edges. The underside of each fingernail was impacted with a dark brown, black hard crusty substance. Resident confirmed he did not like his nails that long or dirty. Resident stated, I can't cut them myself. Resident revealed staff had never requested or assisted with cleaning or trimming his nails. Observation on 09/16/21 at 08:54 A.M. with Licensed Practical Nurse (LPN) #505 confirmed Resident #35 fingernails continued to be long, jagged and partially broken. Resident's fingernails continued to be impacted with the dark brown, black hard crusty substance. Resident verified no one had cleaned or requested to trim his nails since he was admitted . LPN # 505 revealed she normally did not work that hall and was unsure why the nails were not cleaned or trimmed. Interview on 09/16/21 at 11:21 A.M. with Corporate Clinical Coordinator Registered Nurse (RN) #612 verified resident did not receive the scheduled showers and revealed she was unsure why the showers were not completed, and nails were not routinely and as needed cleaned or trimmed. Interview on 09/16/21 11:34 A.M. with State Testing Nursing Assistant (STNA) #609 revealed sometimes they are short staffed and do not have time to complete the showers or the residents nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 6 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to properly assess Resident #35 after a fall. In addition, the facility failed to ensure Resident #291 safely smoked based on the individualized smoking assessment. This affected two residents (Resident #35 and Resident #291) of five residents reviewed for accidents. Findings include: 1. Record review for Resident #35 revealed an admission date of 07/13/21 with diagnoses including adult failure to thrive, difficulty in walking and muscle weakness. Diagnosis dated 09/08/21 included fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing. Record review of Resident #35's fall assessment, dated 07/14/21, revealed the resident was at risk for fall related injury and falls related to weakness and history of falling. Review of Resident #35's care plan, dated 07/14/21, revealed the resident was at risk for fall related injury and falls related to history of falling. The resident had an activities of daily living self-care performance deficit and required assistance with activities of daily living. The resident required extensive assistance of two staff members for bed mobility, and transfers. Review of Resident #35's Minimum Data Set (MDS) 3.0, dated 07/20/21, revealed the resident's cognition was moderately impaired. Resident #35 required two person assistance for bed mobility, transfers, and toilet use, and extensive assistance of one person for walking in the room, dressing, and personal hygiene. Record review of the facility electronic medical records utilized by State Tested Nursing Assistants (STNA) to review Resident #35's plan of care, revealed Resident #35 required extensive assistance with transfers of two staff members and the resident required extensive assistance of one staff member to dress. Record review of the nursing progress note, dated 09/05/21 at 9:35 A.M. completed by Licensed Practical Nurse (LPN) #513, revealed Resident #35 self-reported a fall and stated he just [NAME] fell getting dressed. Resident #35 complained of a three out of 10 pain in the left hip, and the resident declined any pain medication. The resident denied any pain with palpation of hips, legs equal in length no internal or external rotation noted. Moveable bruised soft lump without pain, with or without palpation noted to left medius gluteus (a muscle that helps with hip movement). The nurse practitioner was notified. STAT two view X-ray of the left hip was ordered. At 2:19 P.M. X-ray of left hip was completed. Record review of Resident #35's progress note, dated 09/05/21 at 4:06 P.M. completed by LPN #501, revealed the STAT X-ray came back and the nurse practitioner was notified and new orders were received to send the resident to the hospital for a fracture. At 4:02 P.M. the resident left facility. Record review of Resident #35's nursing progress note, dated 09/08/21 at 5:49 P.M. completed by LPN #544, revealed the resident had returned from the hospital. The resident's right hip had a surgical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 7 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 incision that was covered with a dry dressing. The dressing was intact. Level of Harm - Minimal harm or potential for actual harm Interview on 09/14/21 at 07:49 A.M. with Resident #35 revealed, Sometimes they don't come when I need help, one time I fell and they didn't come for over an hour. Resident #35 confirmed prior to the fall on the morning of 09/05/21, he had dressed himself, he was turning to sit back in the wheelchair when he fell, and he got himself back in the wheelchair and put his call light on. The STNA (unable to recall the name) came in, he told her he fell, and his hip hurt. Resident #35 confirmed the STNA turned the call light off, said she would get the nurse, then no one came back for over an hour until his roommate put his call light on to ask for the nurse to assist him. An STNA came in and took him to the nurse. Residents Affected - Few Interview on 09/14/21 at 1:57 P.M. with LPN #513 revealed STNA #563 came and told her Resident #35 reported a unwitnessed fall. LPN #513 stated, when STNA #563 came and told me, I was getting morphine orders for a hospice patient, I asked if he was up and can she bring him to me. STNA #563 brought him to me at the nurse's station, and the resident stated he fell, and he first denied pain. When he came to me, he was in his wheelchair. I had him hold the rail in the shower room and stand up, there was a discolored fatty area on the left side, so I put him in bed to check his feet for rotation and palpitation, and he rated his pain a three out of 10. I called the doctor for x-ray stat. LPN #513 confirmed with her statement, I assessed Resident #35 approximately 30 minutes after I was first told, as my hospice patient just turned active and was distressed. LPN #513 confirmed there were three other nurses in the facility that would have been able to assist her when Resident #35 fell. LPN #513 confirmed she did not request any assistance from any nurse until after she had Resident #35 stand and hold on to the bars in the shower room and, she noticed a change in his hip. LPN #513 stated they assisted him back into bed and he stayed in bed until transferred to the hospital. Interview on 09/14/21 at 2:15 P.M. with Corporate Clinical Coordinator Registered Nurse (RN) #612 revealed when Resident #35 fell, the nurse should have gone to the resident to assess the resident after the fall. If the nurse was unavailable, she would have expected LPN #513 to ask another nurse to assist. Corporate Clinical Coordinator Registered Nurse (RN) #612 confirmed the nurse should not have stood the resident up, bearing weight, to assess the resident. Interview on 09/15/21 at 11:30 A.M. with STNA #563 revealed when Resident #35's call light came on, she glanced to see if anyone was around, as this was not her resident. No one was around so she answered the light, it was between 7:30 A.M. and 8:00 A.M. STNA #563 went in his room and he said he just fell. He was sitting up in his wheelchair and said his left hip hurts. STNA $563 stated she did not move him and went into the hall and told LPN #513 that Resident #35 said he had fallen. LPN #513 turned to me and said, yep ok. STNA stated she repeated that the resident had fallen again. STNA #563 stated she reported the fall to Resident #35's caregiver as well, STNA #604. Interview 09/15/21 at 12:20 P.M. with STNA #604 revealed she was the main aid, and during breakfast it was reported to her by STNA #563 that Resident #35 fell. STNA #604 revealed LPN #512 had also told her Resident #35 fell. She stated it was between 8:30 A.M. and 9:00 A.M. when she was told. STNA #604 stated Resident #35's roommate called to see where the nurse was because Resident #35 was not assessed yet. The STNA indicated she stuck her head out of the room and asked LPN #513 if she had assessed Resident #35 yet and to bring Resident #35 to her. Resident #35 was in his wheelchair. STNA #604 indicated LPN #512 asked the resident if he was in pain and he rated it a three on a scale of one to ten. STNA #604 then indicated she and LPN #512 took the resident to the shower room and had him stand with their support using the metal grab bars. STNA #604 stated there was a weird mass (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 8 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 below the left buttock. The nurse instructed the STNA to lay the resident down in bed. Level of Harm - Minimal harm or potential for actual harm Interview on 09/15/21 at 12:40 P.M. with Resident #35 revealed when they took him in the bathroom (clarified shower room) and stood him up, it hurt like the dickens. Residents Affected - Few Record review of the facility policy titled, Fall Management dated 05/2010 revealed when a fall occurs, do not move the resident until he/she has been examined by a nurse. 2. Review of the medical record revealed Resident #291 was admitted to the facility on [DATE] with diagnoses including acute exacerbation of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pneumonia, anxiety disorder, recurrent major depressive disorder and nicotine dependence. Review of the admission comprehensive MDS 3.0 assessment, dated 09/02/21, revealed she was moderately cognitively impaired. She displayed inattention, disorganized thinking, and altered level of consciousness that fluctuates. No behaviors were identified. Review of the smoking evaluation, dated 08/27/21, revealed she required supervision when smoking. Review of the smoking plan of care, initiated 08/27/21, revealed if the interdisciplinary team determined that the resident was an unsafe smoker, the resident was required to wear a protective smoking vest apron or other devices as needed during smoking activity. Staff members would distribute smoking materials to the residents who smoke at the designated smoking times and would supervise and maintain the safety of the resident during smoking. Review of the physician orders, dated 09/03/21, revealed Resident #291 must wear a smoking apron when smoking. Resident #291 was observed smoking on 09/13/21 at 2:39 P.M., 09/14/21 at 9:33 A.M. and 09/14/21 at 1:41 P.M. On 09/14/21 at 1:43 P.M. Resident #291 was observed to drop her lit cigarette onto the table, it rolled onto her hospital gown and onto the ground. Resident #291 was looking for it on her gown and socks. On 09/14/21 at 1:45 P.M. Door Greeter #611 was observed to pick up the cigarette from the ground and hand it back to Resident #291 who continued to smoke it. Interview with Resident #291 on 09/14/21 at 11:39 A.M. reported she had spilled coffee on herself this morning and then pudding and had to have her gowns changed twice. She reported she does not wear a smoking apron while smoking. Interview with the administrator on 09/14/21 at 1:51 P.M. reported all smokers were supervised due to COVID-19. She indicated Door Greeter #611 was supervising the smoking currently. She was not aware of any current resident requiring an apron for safe smoking. She was informed Resident #291 had a current order to use a smoking apron. Further interview with the administrator on 09/14/21 at 2:18 P.M. indicated they had not had an order to use a smoking apron with a resident for over a year and began educating the staff. The deficiency substantiates Complaint Number OH00125734. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 9 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and document reviews, the facility failed to maintain sufficient levels of nursing staff to ensure resident care needs and preferences were met. This had the potential to affect all 86 residents that resided in the facility. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) Assessment, dated 07/12/21, revealed the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive assistance of one staff for personal hygiene, and limited assistance of one staff for locomotion via wheelchair. Review of the care plan dated 03/24/21 revealed the resident had an ADL self care performance deficit and required assistance with ADL's and mobility related to activity intolerance, fatigue, weakness, impaired balance, pain, shortness of breath and diagnoses. Interventions included extensive staff assistance for personal hygiene and bathing, she had a preference for showers, and showers were on Mondays, Wednesdays, Fridays, and as needed. Review of Resident #34's shower documentation for July 2021, August 2021, and September 2021 revealed the following: For July 2021, the resident didn't receive her scheduled showers on 07/07/21, 07/24/21, and 07/28/21. For August 2021, the resident didn't receive showers on 08/04/21, 08/07/21, 08/11/21, 08/14/21, 08/21/21, and 08/25/21. For September 2021, the resident didn't receive showers on 09/01/21, 09/04/21, 09/06/21, and 09/08/21. Interview on 09/13/21 at 10:08 A.M. with Resident #34 revealed she wasn't receiving her showers in general/per her preference due to lack of staff at the facility. Interview on 09/15/21 at 11:50 A.M. with the Director of Nursing (DON) revealed residents shower preferences are documented in the care plan. Interview on 09/15/21 at 12:22 P.M. with the Administrator confirmed the above absence of showers for Resident #34. Review of the facility policy and procedure titled, Tub Baths and Showers, undated, revealed the facility policy was that residents require a minimum of one shower weekly. 2. Review of the medical record for Resident #43 revealed an admission date of 11/14/12. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), other schizoaffective disorders, delusional disorders, bipolar disorder, major depressive disorder, morbid obesity due to excess calories, adult failure to thrive, displaced fracture of the left lower leg, pain in bilateral shoulders, and abnormal posture. Review of the quarterly Minimum Data Set (MDS) assessment on 07/16/21 revealed Resident #43 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 10 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 0725 severely impaired cognition and was totally dependent on staff for assistance with bathing. Level of Harm - Minimal harm or potential for actual harm Review of the Individual Care Service Plan, dated 09/16/21, revealed Resident #43 required total staff assistance from one staff for bathing. The resident should receive a shower two times per week on Wednesdays and Saturdays and as needed (prn). Residents Affected - Many Review of the plan of care, dated 02/28/19, revealed Resident #43 had a self-care performance deficit with completing Activities of Daily Living (ADL's) and required staff assistance. Interventions for bathing included the resident required total staff assistance from one staff person. Showers should be offered two times per week on Wednesdays and Saturdays and prn. Review of shower logs from 08/01/21 through 09/16/21 revealed Resident #43 did not receive a shower as scheduled on 8/14/21, 08/21/21, 09/04/21, 09/08/21, 09/11/21, or 09/15/21. Interview on 09/13/21 at 3:07 P.M. with Resident #43 revealed the resident did not receive showers as scheduled. Interview on 09/15/21 at 12:25 P.M. with the Administrator confirmed Resident #43 had not received showers as scheduled in August and September 2021. The Administrator stated she was looking into the issue but was not sure why the resident had not received showers as scheduled on Wednesdays and Saturdays. 3. Review of the medical record for Resident #76 revealed an admission date on 02/01/19 with medical diagnoses including chronic respiratory failure, unspecified asthma, cerebral infarction (stroke), major depressive disorder, generalized anxiety disorder, chronic viral hepatitis C, hemiplegia and hemiparesis following cerebrovascular disease affecting an unspecified side, generalized weakness, contracture of left knee, and shortness of breath. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/17/21, revealed Resident #76 had intact cognition and required extensive assistance from one to two staff persons to complete Activities of Daily Living (ADL's). The bathing activity itself did not occur during the review period. Review of the plan of care for Resident #76, revised 08/27/21, revealed the resident had a self-care performance deficit with completing ADL's. Interventions included Resident #76 required extensive assistance from one staff person to complete bathing. The resident should be offered showers two times per week on Thursdays and Sundays and as needed (prn). Review of the Individual Care Service Plan for Resident #76, dated 09/16/21, revealed the resident required extensive assistance from one staff person to complete bathing. The resident should be offered showers two times per week on Thursdays and Sundays and as needed. Review of shower logs from 07/01/21 through 09/16/21 revealed Resident #76 was scheduled for showers three times per week on Tuesdays, Thursdays, and Saturdays. The resident did not receive showers as scheduled. The resident missed showers on 07/06/21, 07/13/21, 07/15/21, 07/18/21, 07/25/21, 07/29/21, 08/01/21, 08/03/21, 08/08/21, 08/15/21, 08/17/21, 08/24/21, 08/31/21, 09/02/21, 09/05/21, 09/07/21, or 09/14/21. Interview on 09/13/21 at 2:07 P.M. with Resident #76 revealed the resident only received showers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 11 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many when it was convenient for the staff. The resident stated she usually only received a shower once a week and was supposed to receive a shower three times a week on Tuesdays, Thursdays, and Saturdays. The resident stated she received a shower yesterday, 09/12/21, but had not received a shower in an entire week prior to that shower. The resident stated she only wanted a shower and would not accept a bed bath. Interview on 09/15/21 at 9:26 A.M. with Resident #76 revealed she did not receive a shower as scheduled yesterday, 09/14/21. Interview on 09/14/21 at 4:51 P.M. with the Administrator confirmed Resident #76 was scheduled to receive showers three times a week on Tuesdays, Thursdays, and Saturdays. The Administrator confirmed the resident did not receive showers as scheduled in July, August, or September. The Administrator stated she was looking into the issue but had not determined why the resident had not received showers as scheduled. 4. Resident #80 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T11-T12, history of falls, dementia without behavioral disturbance, recurrent major depressive disorder, acute congestive heart failure, shortness of breath and nondisplaced intertrochanteric fracture of right femur. Review of Resident #80's comprehensive MDS assessment, dated 08/19/21, revealed the resident had moderate cognitive impairment and required the extensive assistance of one staff person for dressing and personal hygiene. The bathing activity was marked as not occurring during the assessment period. Review of the Resident #80's individual service care plan indicated she preferred a shower before bed. Interventions included offer showers three times per week on Tuesdays, Thursdays and Saturdays and as needed. Nails were to be trimmed on shower days. She required extensive assistance of one with bathing and staff to provide a sponge bath when a full bath or shower could not be tolerated. Review of the shower documentation from July 2021, revealed Resident #80 only received seven of 13 scheduled showers plus she refused two. August 2021 shower documentation revealed she received six of 13 scheduled showers plus she refused two. September 2021 shower documentation revealed she only received two of six scheduled showers. Interview with Resident #80 on 09/14/21 at 9:27 A.M. revealed she was not consistently receiving showers. She was observed with uncombed hair and long nails. Interview with the administrator on 09/15/21 at 11:30 A.M. reported the provided shower records were the only shower records found. 5. Record review for Resident #35 revealed an admission date of 07/13/21. Diagnosis included adult failure to thrive, difficulty in walking and muscle weakness. Review of Resident #35's Minimum Data Set (MDS) assessment, dated 07/20/21, revealed resident the resident had moderately impaired cognition. The resident required two- person assistance for bed mobility, transfers, and toilet use, extensive assistance of one person for walking in the room, dressing, and personal hygiene. Review of the care plan, dated 07/14/21, revealed the resident had an activities of daily living (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 12 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many self-care performance deficit and required assistance with activities of daily living. Resident #35 required extensive assist of one person to dress and for personal hygiene. Interventions included to check nail length and trim and clean on bath day and as necessary. Record review of the shower sheets revealed resident was scheduled to receive a shower on Mondays and Thursdays. Record review of the shower record for September 2021 revealed resident did not receive a shower or bath on 09/09/21 or 09/13/21. Observation on 09/14/21 at 07:52 A.M. revealed Resident #35 sitting up in his bed eating breakfast. Resident #35's fingernails were approximately ½ to ¾ inch long in length, uneven and partially broken with sharp edges. The underside of each fingernail was impacted with a dark brown, black hard crusty substance. Resident confirmed he did not like his nails that long or dirty. Resident stated, I can't cut them myself. Resident revealed staff had never requested or assisted with cleaning or trimming his nails. Observation on 09/16/21 at 08:54 A.M. with Licensed Practical Nurse (LPN) #505 confirmed Resident #35 fingernails continued to be long, jagged and partially broken. Resident's fingernails continued to be impacted with the dark brown, black hard crusty substance. Resident verified no one had cleaned or requested to trim his nails since he was admitted . LPN # 505 revealed she normally did not work that hall and was unsure why the nails were not cleaned or trimmed. Interview on 09/16/21 at 11:21 A.M. with Corporate Clinical Coordinator Registered Nurse (RN) #612 verified resident did not receive the scheduled showers and revealed she was unsure why the showers were not completed, and nails were not routinely and as needed cleaned or trimmed. Interview on 09/16/21 11:34 A.M. with State Testing Nursing Assistant (STNA) #609 revealed sometimes they are short staffed and do not have time to complete the showers or the residents nails. 6. Interviews during the initial screening of all residents between 09/13/21 at 10:08 A.M. and 09/14/21 at 9:23 A.M. revealed nine residents (#27, #29, #32, #34, #35, #43, #47, #48, #76 and #80) voiced concerns related to staffing including: not enough to receive their showers, excessive times for call lights to be answered (1-2.5 hours) resulting in incontinence, a resident fell and no staff responded for an hour, and staff answering timely but not providing the care or services needed, turning off the light and not returning. 7. Review of the concern logs and concern forms since 03/01/21 revealed 27 complaints were reported by 25 residents (#15, #17, #26, #32, #34, #44, #46, #51, #54, #59, #73, #76, #77, #80, #81, #83, #89, #91, #298, #299, #300, #301, #302, #303 and #304) related to lack to showers or general care. There were nine complaints by Resident's #26, #57, #73, #89, #298, #304, #305, #306 and #307 related to call light response time and four complaints by Resident's #19, #48, #304 and #308 related to not getting up or going to bed as desire due to a lack of staff. 8. Interviews with four Licensed Practical Nurses (LPN)'s #501, #516, #578 and #587 and State Tested Nurse Aide (STNA) #563 between 09/13/21 at 6:28 A.M. to 09/15/21 at 1:17 P.M. reported the facility did not have enough staff to meet the resident's needs. They indicated they were not able to complete showers, answer call lights timely, or pass medications in the required timeframe. 9. Review of the resident council meeting minutes, dated 06/04/21 for old business of the need for more STNA's, revealed the resolution was increasing staff and indicated the PPD always remained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 13 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2.50. The minutes included one resident requested four times to get up because she wanted to play BINGO and was not gotten up. Review of the meeting minutes, dated 07/05/21, indicated no concerns. Review of the meeting minutes, dated 08/02/21, revealed concerns of staff not honoring get up preferences. 10. Review of the facility assessment, dated 01/13/21, revealed for an average daily census of 89 residents, the facility should staff nine licensed nurses and 22 nurse aides providing direct care in a 24 hour period. The acuity the facility accepts as residents include residents on chemotherapy/radiation, oxygen, tracheostomy, BiPAP, CPAP, suctioning, behavioral health needs, dementia, depression, intravenous medications, dialysis, ostomy, Hospice, and active infectious disease. Completion of the State of Ohio staffing tool completed with the administrator on 09/16/21 at 12:00 P.M. revealed for 09/10/21 with a census of 85 residents the facility provided 19 STNA's for the day, on 09/11/21 with a census of 86 residents the facility provided 17 STNA's for the day and on 09/12/21 with a census of 85 residents the facility provided 18 STNA's for the day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 14 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 and staff interview, the facility failed to complete monthly pharmacy recommendations. This affected three residents (#34, #47 and #69) out of six residents reviewed for unnecessary medications. Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact, and required extensive assistance of two staff for bed mobility, transfers, and toilet use, and limited assistance of one staff for locomotion via wheelchair. Review of Resident #34's physician orders revealed orders for Trazodone 50 milligrams (mg) at night for insomnia, Latuda 20 mg for schizophrenia, Buspirone 10 mg twice daily, Eliquis 2.5 mg twice daily for blood clot prevention, and Alprazolam 1 mg three times daily for anxiety. Review of the care plan, dated 03/26/21, revealed the resident had the potential for fluctuations in mood related to disease processes, depression, anxiety, insomnia, and schizophrenia with interventions to administer medications as ordered, assist to identify strengths, positive coping skills, attempt non-pharmacological interventions to decrease mood exacerbations, and in-house counseling as needed. Review of the care plan, dated 04/03/21, revealed the resident was at risk for abnormal bleeding/bruising related to anticoagulant medication use with interventions to administer medications as ordered and obtain labs and diagnostics as ordered and report abnormal findings to the physician. In addition, the resident had an alteration in sleeping pattern related to taking Trazodone for a diagnoses of insomnia with interventions to assist her to identify circumstances that interrupt sleep, attempt non-pharmacological interventions to improve sleep, encourage a consistent daily schedule for rest and sleep and dose reduction attempted as appropriate. Review of Resident #34's medication regimen reviews revealed on 05/18/21 the pharmacist recommended the physician decrease the resident Eliquis from 5 mg twice daily to 2.5 mg twice daily with a rationale that after the initial six months of deep vein thrombosis/pulmonary embolism (DVT/PE) treatment, the manufacturer recommends a lower dose when on going prophylaxis was deemed necessary. On 07/26/21 the physician accepted the recommendation and ordered the resident to receive Eliquis 2.5 mg twice daily. On 05/18/21 the pharmacist also recommended the physician decrease one out of two antipsychotics the resident was on. The resident was receiving Quetiapine Fumarate 50 mg and Latuda 20 mg and the recommendation was to decrease one of them due to possible drug interactions. On 07/26/21 the physician accepted the recommendation and decreased the residents Quetiapine to 25 mg daily. On 06/09/21 the pharmacist recommended a gradual dose reduction (GDR) for Alprazolam 1 mg three times daily and/or Buspar 10 mg twice daily. On 06/21/21 the physician declined the recommendation checking a box that stated a GDR was clinically contraindicated because its continued use was in accordance with current standards of practice and a GDR would impair the individuals ability to function or cause psychiatric instability as documented below. It stated Please provide Centers for Medicare and Medicaid Services (CMS) REQUIRED patient-specific rationale describing why a GDR attempt is likely to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 15 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 impair function or cause psychiatric instability in this individual: The area to document the rationale was left blank. Interview on 09/16/21 at 9:31 A.M. with Registered Nurse (RN) Clinical Coordinator #612 revealed the facility had no specified time frame for when medication regimen reviews should be reviewed by the physician but she would expect one to two weeks. She also stated it was the expectation of the physician to document the rational if they declined a recommendation. RN Clinical Coordinator #612 confirmed the medication regimen reviews were not reviewed timely and further confirmed the absence of rationale documentation. 2. Review of the medical record for Resident #47 revealed an admission date of 01/16/21 and the diagnoses of rhabdomyolysis, anxiety, fracture of left humorous, sciatica, insomnia, depression, muscle weakness, and nicotine dependence. Review of the Minimum Data Set (MDS) assessment, dated 07/23/21, revealed the resident had a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition, and the resident required extensive assistance of two staff for bed mobility, extensive assistance of one staff for transfers, supervision for locomotion via wheelchair, and limited assistance of one staff for toilet use and personal hygiene. Review of Resident #47's physician orders revealed orders for Gabapentin 600 milligrams (mg) three times daily, Duloxetine 60 mg daily, Trazodone 50 mg at night, Morphine 15 mg every six hours as needed for pain, Zolpdiem 10 mg daily, and Hydralizine 50 mg three times daily. Review of Resident #47's medication regimen reviews (MRR) revealed the March 2021 and May 2021 MRR's were missing. Interview on 09/16/21 at 9:31 A.M. with Registered Nurse (RN) Clinical Coordinator #612 confirmed the absence of medication regimen reviews for the months of March 2021 and May 2021 for Resident #47. 3. Review of the medical record for Resident #69 revealed an admission date of 08/10/21 and the diagnoses of cellulitus of left an right lower limbs, muscle weakness, difficulty walking, atrial fibrillation, high blood pressure, high blood pressure, anemia, anxiety disorder, rheumatoid arthritis, gout, Hepititus B, osteoporosis, anxiety, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 08/17/21, revealed the resident's cognition was intact, required extensive assistance of two staff for bed mobility and transfers and toileting, extensive one assist for locomotion via wheel chair, personal hygiene and dressing, and supervision for eating. Review of Resident #69's physician orders revealed orders for Lasix Tablet 40 milligrams (mg) daily for edema, Buspirone 15 mg with instructions to give 0.5 mg twice daily, Xanax 0.25 mg as needed for anxiety, Remeron 7.5 mg at night for appetite, and prostat64 30 milliliters (ml) twice daily for protein calorie malnutrition. Review of the Medication Regimen Review, dated 08/11/21, revealed the review was completed and recommendations were made, but there was no documented evidence of what the recommendation was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 16 of 17 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 365404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of MT Vernon The 13 Avalon Road Mount Vernon, OH 43050 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 Interview on 09/16/21 at 9:31 A.M. with Registered Nurse (RN) Clinical Coordinator #612 confirmed the absence of a medication regimen review for the month of August 2021 for Resident #69. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 17 of 17