Health inspection·October 19, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mobility and transfers. The assessment also noted the resident used a wheelchair for mobility and had a history of falls since admission to the facility. Observations on 10/16/23 at 9:30 A.M. and again at 12:14 P.M. revealed Resident #42 sitting in the wheelchair self-propelling in the activity area and then sitting at a dining room table during the lunch meal with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy. Observations on 10/17/23 at 7:34 A.M. and 11:50 A.M., and again at 2:49 P.M. revealed Resident #42 siting at a dining room table during the breakfast meal and self-propelling in the wheelchair throughout the hallway and lounge area with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy. Observations on 10/18/23 at 7:29 A.M., 9:30 A.M., and again at 10:16 A.M. revealed Resident #42 was self-propelling throughout the dining room and lounge area in the wheelchair with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy. Observation on 10/18/23 at 12:05 P.M. revealed Resident #42 was sitting at a dining room table during the lunch meal. The lap buddy was partially attached to the left armrest and was completely attached to the right armrest. The lap buddy was positioned in an upward angle from Resident #42's lap. Resident #42 was continually rolling forward towards the table in an attempt to reach the plate of food. The positioning of the lap buddy was prohibiting Resident #42 from getting up next to the table and the plate of food located on the table in front of her. After several attempts to get up next to the table, Resident #42 reversed the wheelchair and self-propelled out of the dining room. Observation of Resident #42's plate revealed less than 25 percent (%) of her meal was consumed. Observation on 10/18/23 at 2:01 P.M. revealed Resident #42 was participating in activities and was eating an ice cream sundae. Resident #42 was sitting in the wheelchair with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy. Interview on 10/18/23 at 12:05 P.M. with State Tested Nursing Assistant (STNA) #228 revealed Resident #42 usually required verbal cues to eat meals. STNA #228 stated, She usually only drinks cranberry juice and eats the ice cream. Her best meal is breakfast. She always has that lap buddy in the wheelchair. Interview on 10/18/23 at 2:49 P.M. with STNA #214 revealed the lap buddy was there to prevent the resident from standing up from the wheelchair. STNA #214 stated, She would always try to stand up from the wheelchair and several times she has fallen and hurt herself. I would remove it when I must change her or when I put her to bed. Interview on 10/18/23 at 3:04 P.M. with Registered Nurse (RN) #204 revealed the lap buddy was in place for Resident #42 due to multiple falls when Resident #42 would attempt to stand up from the wheelchair. Interview on 10/18/23 at 3:11 P.M. with the Director of Nursing (DON) revealed Resident #42 could remove the lap buddy from the wheelchair and if staff attempted to remove the lap buddy, Resident #42 would start to yell at the staff. The DON revealed therapy staff would evaluate Resident #42 for appropriate positioning in the wheelchair. Interview on 10/18/23 at 3:21 P.M. with Unit Manager Licensed Practical Nurse (LPN) #219 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 2 of 19 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 10/19/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Physical Device Evaluations were to be completed upon implementation of the device and then quarterly to ensure the device was still appropriate. LPN #219 confirmed there had been only the initial evaluation completed on 10/10/22 and a quarterly evaluation completed on 07/20/23 for the use of the lap buddy for Resident #42. Interview on 10/18/23 at 3:36 P.M. with Therapy Staff #260 revealed Resident #42 would remove the lap buddy and transfer to the couch to lay down and watch television. Therapy Staff #42 stated, Her cognition has rapidly declined due to Huntington's Disease. She doesn't really know how to remove the lap buddy now. She seems to like having it in place, it must make her feel safe. On 10/16/23 at 11:00 A.M. and again on 10/18/23 at 8:15 A.M. Resident #42 was asked if she was able to remove the lap buddy from the wheelchair. The resident made no attempt to remove it upon request. Review of the facility policy titled, Restraint Management, revised date 03/07/23, revealed when a resident's condition necessitates consideration for a restraint, alternative interventions must be attempted and documented on the Physical Device Evaluation and in the care plan. During the time a restraint is in place, the restraint is periodically removed. Restraints should always be removed during supervised mealtimes and activities unless clinical contraindications are documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 3 of 19 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 10/19/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure medications were administered as ordered to treat medical conditions of Resident #59 and/or medications were administered as needed/ordered based on the resident's hemodialysis schedule. This affected one resident (#59) of six residents reviewed for unnecessary medication use. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #59 revealed an admission date of 07/03/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, chronic viral hepatitis C, unspecified protein-calorie malnutrition, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. She was on a therapeutic diet. She was on dialysis. Review of the physician order dated 10/10/23 revealed Resident #59 had dialysis at DaVita every Tuesday, Thursday, and Saturday. a. Review of the physician order dated 07/03/23 revealed an order for Carvedilol (beta blocker to treat high blood pressure) oral tablet 25 milligrams (mg) one tablet by mouth two times a day for hypertension. Review of the physician order dated 07/04/23 revealed Resident #59 was to receive Amlodipine Besylate (calcium channel blocker to treat high blood pressure) 10 mg one tablet by mouth for hypertension. Review of the October 2023 Medication Administration Record (MAR) revealed Amlodipine Besylate 10 mg and Carvedilol 25 mg were not administered at 8:00 A.M. due to the Resident #59 being 'absent from the home' on 10/03/23, 10/05/23, 10/07/23, 10/10/23, and 10/14/23. On 10/12/23 and 10/17/23 it was indicated to see nurses' notes. Review of the progress notes dated 10/12/23 revealed no reasoning for holding Amlodipine Besylate or Carvedilol. Review of the progress notes dated 10/17/23 revealed only 'dialysis today.' b. Review of the physician order dated 07/03/23 revealed an order for Sevelamer 800 mg (lowers the amount of phosphorus in the blood for residents receiving dialysis) one tablet by mouth with meals for supplement. Review of the October 2023 MAR revealed Sevelamer was not administered due to Resident #59 being 'absent from the home' at 7:30 A.M. on 10/03/23, 10/05/23, 10/07/23, 10/10/23 and 10/15/23 and at 12:00 P.M. on 10/03/23, 10/05/23, 10/07/23, 10/10/23, 10/12/23 and 10/15/23. c. Review of the physician order dated 07/03/23 revealed an order for Senexon-S oral tablet 50 mg two tablets to be administered twice a day for constipation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 4 of 19 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 10/19/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 07/03/23 revealed an order for Cilostazol oral tablet 100 mg (vasodilator) one tablet by mouth two times a day for atrial fibrillation. Review of the physician order dated 07/04/23 revealed Resident #59 was to receive Aspirin low dose tablet delayed release 81 mg one tablet by mouth for preventative. Residents Affected - Few Review of the physician order dated 07/04/23 revealed an order for Topiramate oral tablet 50 mg (anticonvulsant) one tablet by mouth for migraines. Review of the physician order dated 07/04/23 revealed an order for B-Complex oral tablet one time a day for supplement. Review of the physician order dated 07/04/23 revealed an order for Bupropion extended-release oral tablet 150 mg (antidepressant) by mouth one time a day for depression. Review of the physician order dated 07/04/23 revealed an order for cholecalciferol tablet 1000 units (vitamin D supplement) by mouth one time a day for supplement. Review of the physician order dated 07/04/23 to 10/13/23 revealed an order for Omeprazole delayed release 20 mg (proton-pump inhibitor) one capsule by mouth one time a day for gastro-esophageal reflux disease. Review of the physician order dated 07/06/23 revealed an order for liquid protein 30 milliliters (ml) two times a day. Review of the physician order dated 09/04/23 revealed an order for Clopidogrel Bisulfate tablet 75 mg (blood thinner) one tablet by mouth one time a day for atrial fibrillation. Review of the physician order dated 09/19/23 revealed an order for Celexa Oral Tablet 20 mg (antidepressant) one tablet by mouth one time a day for depression. Review of the physician order dated 10/14/23 revealed an order for Omeprazole delayed release 20 mg one capsule by mouth one time a day every other week. Review of the October 2023 MAR revealed Senexon-S 50 mg, Cilostazol 100 mg, Aspirin 81 mg, B-Complex, Bupropion, Celexa, cholecalciferol, Clopidogrel Bisulfate, Omeprazole, Topiramate, liquid protein 30 ml, were not administered at 8:00 A.M. due to Resident #59 being 'absent from the home' on 10/03/23, 10/05/23, 10/07/23, 10/10/23, and 10/14/23. d. Review of the physician order dated 09/18/23 revealed an order for Buspirone oral tablet 5 mg (antianxiety) one tablet by mouth three times a day for anxiety. Review of the October 2023 MAR revealed Buspirone 5 mg was not administered at 12:00 P.M. due to Resident #59 being 'absent from the home' on 10/03/23, 10/05/23, 10/07/23, 10/10/23, and 10/14/23. Interview on 10/18/23 at 10:00 A.M. with the Director of Nursing (DON) verified Resident #59 had not been given medications and supplements as ordered without hold orders. She reported some medication times had been changed on 10/17/23 but verified medications were still not administered as ordered on that day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 5 of 19 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 10/19/2023 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, record review, interview, and facility policy review the facility failed to implement fall interventions for Resident #17. This affected one resident (#17) of two residents reviewed for fall interventions. The facility census was 88. Findings include: Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes mellites type two, sleep apnea, depression, anxiety, and breast cancer. Review of Resident #17 fall investigation dated 03/03/23 revealed Resident #17 slid out of bed and was on the floor beside the bed. Resident #17 had no injuries. Review of Resident #17's fall care plan revised on 03/03/23 revealed the intervention for the fall out of bed was to place a perimeter mattress on Resident #17's bed. Review of Resident #17's physician orders revealed a signed order dated 03/29/23 for a perimeter mattress to bed at all times, check every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers. The assessment also noted the resident used a wheelchair for mobility and had a history of falls since admission to the facility. Observation on 10/16/23 at 11:36 A.M. revealed Resident #17 was lying in bed watching television. Resident #17 was lying on a regular flat bariatric mattress. The sides of mattress were not raised to create a perimeter to the mattress. mattress: on 10/17/23 at 1:52 P.M. with the Director of Nursing (DON) confirmed the mattress that was currently on Resident #17's bed was not a perimeter mattress; it was a regular flat bariatric mattress. Review of the facility's policy titled Fall Management, revised date 09/22/23, revealed The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 6 of 19 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 10/19/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide timely care and interventions for Resident #183 related to a urinary tract infection (UTI). The facility also failed to provide proper oversight, assessment, and follow up of urinary catheters for Resident #60 and Resident #334. This affected one resident (#183) of four residents reviewed for UTI and two residents (#60 and #334) of two residents reviewed for urinary catheters. The facility census was 88. Findings include: 1. Resident #183 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, type II diabetes, hypertension, insomnia, muscle weakness, difficulty walking, cognitive communication deficit, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, enterocolitis, chronic kidney disease (stage III), depression, heart failure, hyperlipidemia, edema, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #183 was cognitively intact. Review of Resident #183's laboratory reports revealed the original urine sample was collected on 09/29/23 due to her having signs/symptoms of a potential UTI. Documentation found that the urine sample was read on 09/30/23, which had six abnormal test results, including white blood cell count, red blood cell count, and urine appearance was cloudy. Then, on 10/04/23, the lab results were read again with the gram-negative rods being abnormal. This prompted the culture and sensitively to being completed. Then, on 10/07/23, the same urine same was reviewed and it determined the urine sample was contaminated, so the sensitivity could not be performed. Review of Resident #183's physician orders dated 10/11/23 revealed a new order for a urinalysis was to be collected to determine if the resident had a UTI. The urine sample was collected on 10/13/23, and the results of the UTI ProX results, which was read on 10/14/23, revealed she had a UTI. Review of Resident #183 physician orders revealed she was prescribed Macrobid (antibiotic) 100 milligrams (mg) twice daily for seven days for a UTI. From the initial onset of symptoms, dated 09/29/23, to the date the treatment was ordered on 10/15/23 it was 16 days. Review of Resident #183 progress notes, dated 09/29/23 to 10/15/23, revealed no documentation to support the facility contacted the lab to determine if there was a problem with the sample prior to a handwritten note on the lab results, dated 10/07/23, and there was no documentation to support they contacted the lab and/or physician to determine why there was a lag time in getting the actual lab results. Interview with the Director of Nursing (DON) on 10/18/23 at 2:59 P.M. and 10/19/23 at 8:41 A.M. confirmed the initial urine sample was taken on 09/29/23, and they did not receive information from the lab that the sample was contaminated to complete the sensitivity until 10/07/23. She confirmed there was no documentation to support communication with the lab to get this information in a timelier manner. She confirmed there was 16 days between the initial urine sample was taken to determine if Resident #183 had a UTI, and when treatment finally started (09/29/23 to 10/15/23). She confirmed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 7 of 19 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 10/19/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is more time than desired to start treatment, which is why they are switching lab companies; she confirmed they have had multiple issues with this lab company. She also agreed the lab should have told the facility prior to 10/07/23 if the initial urine sample was contaminated, especially since they received two lab reports from them prior to getting that information. 2. Review of the medical record for Resident #334 revealed an admission date of 10/04/23 with diagnoses including malignant neoplasm of larynx, acute respiratory failure with hypoxia, non-ST elevation myocardial infarction, chronic kidney disease, obstructive and reflux uropathy, and disorder of the kidney and ureter. Review of a hospital consultation note for Resident #334 dated 09/29/23 revealed a urinary retention assessment and plan. The plan states Urinary Retention: continue indwelling foley catheter upon discharge. Will plan for outpatient voiding trial in 1-2 weeks. Review of Resident #334's physician order dated 10/05/23 states Foley Catheter 18 French (F)/10 cubic centimeters (cc) balloon to gravity drainage. Leave in place until seen by Urologist on 10/09/23 Diagnosis: Obstructive Uropathy. Review of a nurses note dated 10/09/23, Resident #334 was transported by Emergency Medical Services (EMS) to the emergency room. A nurse's note from 10/11/23 states that the resident had returned from the hospital. Review of the October 2023 Administration record for Resident #334 revealed under Unscheduled Other Orders displays Foley Catheter 18F/10cc balloon to gravity drainage. Leave in place until seen by Urologist on 10/09/23 Diagnosis: Obstructive Uropathy. The October 2023 Administration record documents Foley catheter care each shift from 10/05/23 to 10/09/23 and 10/11/23 to 10/17/23. Review of the medical record from 10/04/23 to 10/19/23 for Resident #334 revealed no documentation of the facility consulting with a urologist or having Resident #334's urology appointment rescheduled. Interview on 10/17/23 at 3:53 P.M. with Unit Manager #215 revealed the facility didn't know the appointment for Resident #334 was missed. Interview on 10/18/23 at 10:03 A.M. with the DON revealed they do not have a policy for scheduling or rescheduling appointments. Interview on 10/18/23 at 10:15 A.M. with the DON verified that the urologist was not contacted for Resident #334. 3. Review of the medical record for Resident #60 revealed an admission date of 08/20/21 with diagnoses including other muscle spasm, type II diabetes mellitus, lymphedema, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, bipolar disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #60 had intact cognition. There was no catheter indicated, and she was always continent of bowel and bladder. Review of the plan of care dated 09/30/22 revealed Resident #60 had a history of incontinence of bladder related to limited mobility. Interventions included checking the resident every two hours and as needed for incontinence, encouraging fluids to promote prompted voiding responses, observing for signs and symptoms of UTI, and providing incontinence care as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 8 of 19 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 10/19/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 10/09/23 revealed Resident #60 had a Foley catheter 16 F/30 cc balloon to gravity drainage. Review of the physician order dated 10/10/23 revealed Resident #60 was to get Foley catheter care every shift. Residents Affected - Few Review of the physician order dated 10/10/23 revealed Resident #60's Foley catheter was to be changed every month and as needed. Review of the 10/05/23 nursing comprehensive assessment for readmission revealed Resident #60 had an indwelling Foley catheter due to need for accurate measurement of urinary output. Review of the medical record revealed no evidence the facility was monitoring output from the catheter. Review of the progress notes from 10/05/23 to 10/17/23 revealed no mention of Resident #60's Foley catheter. Review of the medical record revealed no documented evidence the physician assessed Resident #60 for Foley catheter use. Observation on 10/16/23 at 1:41 P.M. of Resident #60 revealed a catheter bag in place. Interview on 10/17/23 at 10:23 A.M. and 11:21 A.M. with Licensed Practical Nurse (LPN) #222 revealed Resident #60 came back from the hospital on [DATE] with a Foley catheter. She verified there was no diagnosis listed in the order or diagnosis list for Resident #60's Foley catheter; however, she believed it was overactive bladder. LPN #222 additionally verified the comprehensive nurse's assessment said the Foley catheter was in place to monitor output; however, the urinary output was not documented. In addition, LPN #222 confirmed there was not a plan of care in place for the Foley catheter. Interview on 10/18/23 at 8:40 A.M. with the DON verified Resident #60 should have not had the Foley catheter in place any longer. She reported from what she could tell, the Foley catheter should have been removed within a week after she returned from the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 9 of 19 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 10/19/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure weekly weights were obtained for Resident #46 who had significant weight loss. This affected one resident (#46) of two residents reviewed for nutrition. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed an admission date of 10/13/22 with diagnoses including Parkinson's disease, dementia, chronic obstructive pulmonary disease, type two diabetes, heart failure, depression, and dysphagia. Review of the plan of care dated 10/18/22 revealed Resident #46 was at nutritional or dehydration risk related to diagnoses, and as of 09/23/23 a significant weight gain or loss in one and three months. Interventions included administering medications as ordered, encouraging choices within ordered diet, observing for signs of dehydration, obtaining labs as ordered, obtaining weight, regular diet, supplements as ordered, and referring to dietitian as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed impaired cognition. Resident #46 had no significant weight changes and was on a mechanically altered and therapeutic diet. Review of Resident #46's weights revealed on 03/08/23 he weighed 127.1 pounds, on 03/10/23 he weighed 127.1 pounds, on 03/17/23 he weighed 129.4 pounds, 03/22/23 he weighed 139 pounds, on 04/13/23 he weighed 140.6 pounds, on 05/02/23 he weighed 135.4 pounds, on 06/20/23 he weighed 132.4 pounds, on 07/26/23 he weighed 131.6 pounds, on 08/03/23 he weighed 131.4 pounds, on 08/16/23 he weighed 134.6 pounds, on 09/08/23 he weighed 130.2 pounds, on 09/14/23 he weighed 130 pounds, and on 09/20/23 he weighed 125.2 pounds which was a 9.9 percent (%) loss over six months, a 7% loss over one month, and a 5.1% loss over three months. His weight was obtained again on 10/18/23 and was 133.4 pounds. Review of the dietary progress note dated 09/21/23 revealed Resident #46 had a significant weight loss. Resident #46's intake was improving, and he was on house supplements. The dietitian recommended adding a supplement shake every day to increase caloric intake and continuing weekly weights. Review of the resident at risk progress note dated 09/21/23 revealed Resident #46 had a significant weight loss. The facility was to continue to monitor his weight weekly. Interview on 10/18/23 at 2:15 P.M. with Diet Technician #304 verified Resident #46 was supposed to be getting weekly weights. Diet Technician #304 reported it was against corporate policy to have orders for weekly weights; however, she made a list weekly of those who needed weighed and provided it to nursing staff. She reported she would check the list on Tuesday's, Thursday's, and Friday's and would send daily reminders of residents who had not been weighed. She was aware Resident #46's weekly weights had not been obtained and said she continued to put him on the list. Interview on 10/19/23 at 8:30 A.M. with the Director of Nursing (DON) verified Resident #46 did not get weighed weekly as he should have. Review of the policy titled Weight Management, dated 09/22/23, revealed residents determined to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 10 of 19 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 10/19/2023 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 0692 at risk or who have had significant weight changes will be weighed on a weekly basis. 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 11 of 19 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 10/19/2023 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 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, record review, and interview the facility failed to ensure respiratory equipment was stored in a clean environment. This affected one resident (#17) of one resident reviewed for respiratory care. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes mellites type II, sleep apnea, depression, anxiety, and breast cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers. Review of Resident #17's physician's orders revealed a signed physician order dated 10/09/23 for Budesonide inhalation suspension (steroid) 0.5 milligram (mg) per milliliter (ml) to be administered 2.0 ml via nebulizer machine every twelve hours for respiratory care. Review of Resident #17's medication administration record (MAR) for October 2023 revealed Budesonide inhalation suspension was administered twice daily (at 8:00 A.M. and at 8:00 P.M.). The administration of this medication was verified and documented by the floor nurse. Observation on 10/16/23 at 11:36 A.M. in Resident #17's room revealed a nebulizer machine located on the top of the three-drawer dresser next to Resident #17's bed. There was tubing connected to the nebulizer machine and a nebulizer mask attached to the end of the tubing which was lying on the floor on the opposite side of the three-drawer dresser from the bed. The tubing and mask were not inside a bag nor was there a barrier on the floor underneath the tubing and mask. Interview on 10/16/23 at 12:02 P.M. with Licensed Practical Nurse (LPN) #305 revealed once the nebulizer medication was administered via the nebulizer mask and tubing, the mask should be rinsed with water and dried then placed in a bag until the next time for administration of the medication. LPN #305 confirmed Resident #17's nebulizer mask and tubing was lying on the floor beside the three-drawer dresser in Resident #17's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 12 of 19 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 10/19/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to complete pre and post dialysis assessments for Resident #59. This affected one resident (#59) of one resident reviewed for dialysis. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #59 revealed an admission date of 07/03/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type II diabetes mellitus, chronic viral hepatitis C, unspecified protein-calorie malnutrition, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. She was on a therapeutic diet. She was on dialysis. Review of the plan of care dated 09/20/23 revealed Resident #59 was at risk for complications related to dialysis due to end stage renal disease. Interventions included administering medications as ordered, not using shunted arm for blood pressure, checking bruit and thrill every shift, utilizing dialysis communication form to communicate with the dialysis center, upon return from dialysis observe resident's access site, and checking and reinforcing dressing at access site as needed. Review of the physician order dated 10/10/23 revealed Resident #59 had dialysis at DaVita every Tuesday, Thursday, and Saturday. Review of Resident #59's dialysis binder on 10/18/23 at 8:55 A.M. revealed the binder was empty. Interview on 10/18/23 at 8:55 A.M. with the Director of Nursing (DON), Registered Nurse (RN) #204, and Licensed Practical Nurse (LPN) #222, verified there were no pre and post dialysis assessments for Resident #59. They reported they had problems getting dialysis to complete the assessments sent with the resident, and many residents had refused to bring the binder since dialysis was not looking at the forms anyway. However, they verified there was no documented evidence pre-dialysis assessments were being completed which would not require dialysis cooperation. Interview on 10/18/23 at 10:00 A.M. with the DON revealed she had spoken to dialysis on that day to restart the dialysis forms, and both facility staff and dialysis staff would be educated. She reported the facility would have to make sure they were sending the forms again as residents were refusing to bring the binders at times. The DON verified there was no documentation present to indicate the resident refused to bring the binder or previous attempts to speak to dialysis about the form. Review of the facility policy titled Hemodialysis, dated 10/14/21, revealed the facility was to complete the appropriate sections of the hemodialysis communication form prior to the resident receiving each dialysis session and again when the resident returned from dialysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 13 of 19 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 10/19/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to comprehensively assess/provide written description of pain and provide evidence of non-pharmacological interventions prior to administering as needed pain medications for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medications. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #60 revealed an admission date of 08/20/21 with diagnoses including other muscle spasm, type II diabetes mellitus, lymphedema, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, bipolar disorder, and hypertension. Review of the plan of care dated 08/23/21 revealed Resident #60 was at risk for pain related to diagnoses, muscle spasms, and back pain. Interventions included administering medications as ordered, anticipating the residents need for pain relief, evaluating the effectiveness of pain interventions, observing for probable cause of pain and removing or limiting causes, offering non-pharmacological interventions, and reporting to the nurse any changes in activity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had intact cognition. Record review revealed Resident #60 had been hospitalized from [DATE] to 10/05/23 for sepsis. Review of the physician order dated 10/06/23 (re-admission) revealed non-pharmacological pain interventions were to be documented when needed. Non-pharmacological interventions included massage, meditation, positioning, ice or cold pack, diversional activity, guided imagery, rest, social interaction, or other. Review of the physician order dated 10/09/23 revealed Resident #60 had an order for Oxycodone HCl oral tablet (opioid pain medication) 5 milligrams (mg), one tablet by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #60 received Oxycodone HCl 5 mg once on 10/07/23, twice on 10/08/23, once on 10/09/23, twice on 10/10/23, once on 10/11/23, 10/12/23, and 10/13/23, twice on 10/14/23, once on 10/15/23, and once on 10/17/23. Additional review revealed no non-pharmacological interventions were documented prior to the administration of the as needed medication. Review of the medication administration progress notes from 10/07/23 to 10/17/23 revealed there were no descriptions or locations given for pain upon administration of Oxycodone HCL. Interview on 10/18/23 at 12:53 P.M. with the Director of Nursing (DON) verified there was no indication non-pharmacological interventions had been attempted and no description of or location of pain. The DON verified that descriptions of pain should have been given and non-pharmacological interventions should have been attempted for every 'as needed' administration. Review of the policy titled Pain Management, dated 04/11/23, revealed staff should ask residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 14 of 19 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 10/19/2023 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 0757 and observe the residents to determine the location of pain. 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 15 of 19 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 10/19/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to have proper justification for the use of psychotropic medication for Resident #75. This affected one resident (#75) of six residents reviewed for unnecessary medications. The facility census was 88. Findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, degenerative disease of nervous system, amnesia, aphasia, hyperlipidemia, cognitive communication deficit, major depressive disorder, insomnia, hypertension, anxiety disorder, and constipation. Review of Resident #75's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. Review of Resident #75's current physician orders revealed she was prescribed Depakote (anticonvulsant used to treat bipolar disorder) 125 milligrams (mg) twice daily for dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #75's psychiatric/mental health report, dated 09/25/23, revealed the resident was prescribed Depakote 125 mg twice daily for dementia with mood disturbances. There was no other documentation to support why Resident #75 should be prescribed Depakote. Interview with Director of Nursing (DON) on 10/18/23 at 11:05 A.M. confirmed Resident #75 was prescribed Depakote for dementia with mood disturbances. She confirmed there were no other diagnoses to support the need for Depakote. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 16 of 19 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 10/19/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, record review, and interview the facility failed to ensure medications were dated and disposed of according to industry standards. This had the potential to affect all 85 residents residing at the facility. The facility census was 88. Findings include: 1. Observation on [DATE] at 7:40 A.M. revealed during medication room review of the facility's second medication room refrigerator and opened multi-use vial of Aplisol Tuberculin solution without the date it was opened. The vial of Aplisol Tuberculin solution had been delivered from the pharmacy on [DATE] and had an expiration date of 09/2024. Interview on [DATE] at 7:55 A.M. with Licensed Practical Nurse (LPN) #212 confirmed the opened multi-use vial of Aplisol Tuberculin solution did not have the date it was opened, and the vial was delivered to the facility from the pharmacy on [DATE]. Review of the manufacturer's information sheet for Aplisol Tuberculin solution revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 2. Observation on [DATE] at 11:37 A.M. of the facility's 400 Hallway medication cart revealed an open bottle of over-the-counter Artificial Tears eye drops with no resident's name or date it was opened. Interview on [DATE] at 11:40 A.M. with LPN #222 confirmed the open bottle of over-the-counter Artificial Tears eye drops with no resident's name or dated it was opened in the drawer of the 400 Hallway medication cart. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, revised date [DATE] revealed, Once any medication or biological package is opened, facility should follow the manufacturer's guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container. 3. Observation on [DATE] at 7:50 A.M. revealed during the medication storage room review of the facility's main medication storage room on the shelves for stock medications, an over-the-counter unopened bottle of Magnesium Tablets 500 milligram (mg) with an expiration date of 09/2023. Interview on [DATE] at 8:00 A.M. with LPN #212 confirmed the expired over - the-counter bottle of Magnesium Tablets 500 mg in the facility's main medication storage room. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals revised date [DATE] revealed, Facility should ensure that medications and biologicals that (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer guidelines; (3) have been contaminated or deteriorated, are stored separate from the other medications until destroyed or returned to the pharmacy or supplier. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 17 of 19 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 10/19/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to maintain a safe, homelike environment. This affected two residents (#17 and #21) of 88 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #21 was re-admitted to the facility on [DATE] with the diagnoses including obesity, bipolar disorder, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition and required extensive assistance from staff to complete activities of daily living (ADL) tasks including bed mobility and transfers. Observation on 10/16/23 at 9:25 A.M. revealed Resident #21's half of the room was nearest the window. Resident #21 uses a large bariatric bed which was in the far corner of the room beneath the light fixture. Immediately to the left side of Resident #21's bed was a wall with multiple patched areas. The wall was blue in color, and the patched areas were white in color with rough edges located throughout the patched material. On the wall directly behind the headboard of Resident #21's bed were large, long gouges with exposed drywall material. Further observation revealed Resident #21's land line phone connection box cover was unattached to the phone connection box. The land line phone wire was protruding from the phone connection box with the connection box cover hanging from the end of the wire which was attached to the phone jack with exposed individual wires noted. Interview on 10/16/23 at 1:35 P.M. with Licensed Practical Nurse (LPN) #305 confirmed the multiple patched areas to the wall on the left side of Resident #21's bed, the large, long gouges to the wall behind Resident #21's headboard to the bed, the unattached phone connection box cover, and the exposed wires attached to the phone jack hanging out of the phone connection box. 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes mellites type two, sleep apnea, depression, anxiety, and breast cancer. Review of the MDS assessment dated [DATE] revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers. Observation on 10/16/23 at 10:26 A.M. revealed Resident #17's half of the room was nearest the window. Resident #17 uses a large bariatric bed which was in the far corner of the room underneath the light fixture. Further observation revealed approximately two feet up the wall from the floor were long large gouges in the wall with drywall material exposed. Directly above the baseboard was a linear penetration in the wall approximately twelve inches in length and at the widest section approximately four inches wide. At the widest section there was a hole approximately two inches in diameter with exposed drywall material and wood particles from the wall support structures. There was an empty rodent glue trap lying on the floor underneath Resident #17's bed and directly in front of the wall penetration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365404 If continuation sheet Page 18 of 19 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 10/19/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 10/16/23 at 1:20 P.M. with LPN #305 confirmed in Resident #17's room the long, large gouges in the wall with exposed drywall material, the linear wall penetration with a hole located in the center of the penetration above the baseboard, and the empty rodent glue trap lying on the floor underneath Resident #17's bed and in front of the hole in the wall penetration. Review of the facility resident admission paperwork booklet titled Federal & Ohio Resident Rights & Facility Responsibilities revealed in the section of Residents' rights; sponsor may protect rights. (3721.13) Safe and Clean-Living Environment. The right to a safe and clean-living environment pursuant to the Medicare and Medicaid programs. Event ID: Facility ID: 365404 If continuation sheet Page 19 of 19