Health inspection·November 1, 2018

F 0607 Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 10/31/18 at 11:19 A.M. confirmed the DON had notified him on 10/22/18 that Resident #28 had punched Resident #54. The Administrator confirmed the incident involving possible physical abuse between Residents #28 and #54 had not been investigated or reported to the state agency, because the residents involved were not injured and he didn't believe that Resident #28 had an intent to injure Resident #54. Residents Affected - Few Review of the facility's Abuse Prohibition, Investigation and Reporting policy dated 12/2017 revealed reports of alleged abuse will be immediately reported to the Administrator and thoroughly invested. Further review of the policy revealed allegations of abuse will be reported to the state regulatory agency as required by state and federal law. Based on record review, interviews, review of facility Self-Reported Incidents (SRI's) and review of facility policy the facility failed to implement their abuse policy after receiving an allegation of resident to resident physical abuse. This affected four Residents (#28, #54, #92 and #110) of four reviewed for abuse. The facility census was 124. Findings include: 1. Record review revealed Resident #92 was admitted to the facility on [DATE] with the following diagnoses; hypertension, dysphagia, muscle weakness, vascular dementia with behavioral disturbance, irritable bowel syndrome without diarrhea, and abnormal findings of blood chemistry. Review of Resident #92's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Resident #92 was reported to exhibit behaviors not directed towards others. Review of Resident #92's progress note dated 09/13/18 revealed the resident received physical aggression from another resident at lunch. Further review of the progress note revealed the residents were separated and Resident #92's physician and resident representative were notified of the incident. Resident #92 did not have any visible injuries as a result of the incident and the facility's supervisor was notified. 2. Record review revealed Resident #110 was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, malignant neoplasm of frontal lobe, type one diabetes mellitus, epilepsy, mood disorder and hypothyroidism. Review of Resident #110's annual (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility. Resident #110 also required extensive assistance with transfers, dressing, toileting and personal hygiene and supervision with eating on the 09/14/18 MDS. Resident #110 was reported to have behaviors directed towards others, verbal behaviors and behaviors not directed towards others on the 09/14/18 MDS. Review of Resident #110's progress note dated 09/13/18 revealed the resident pulled another resident's hair with her hands at lunch. Further review of the progress note revealed the residents were separated and Resident #110's physician and the facility's supervisor were notified of the incident Review of the facility's SRI's on 10/30/18 revealed there was no SRI completed for the incident between Resident #110 and Resident #92 on 09/13/18. Interview with Licensed Practical Nurse (LPN) #183 on 10/31/18 at 10:30 A.M. revealed she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 2 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remember the altercation between Resident #110 and #92 on 09/13/18. LPN #183 stated the incident happened because she documented it in the medical record. LPN #183 also reported residents that have altercations were immediately separated and redirected. Interview with the Director of Nursing (DON) on 10/31/18 at 1:46 P.M. revealed the DON was made aware of the incident when Resident #110 pulled Resident #92's hair on 09/13/18. The DON reported she notified the Administrator of the incident and the residents were immediately separated. Interview with the Administrator on 11/01/18 at 7:32 A.M. verified that a SRI and an investigation were not completed after Resident #110 pulled Resident #92's hair on 09/13/18. The Administrator stated he did not do a SRI or an investigation of the incident on 09/13/18 due to the incident being witnessed, a history of both residents having dementia and no injuries resulted from the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 3 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #54 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance and anxiety disorder. Review of the MDS dated [DATE] revealed Resident #54 was cognitively intact and required assistance with activities of daily living. Review of nurse progress note dated 10/22/18 at 4:30 P.M. for revealed staff witnessed another resident (Resident #28) punch Resident #54 in the face. Further review of the nurse progress revealed Resident #54 was assessed for injuries with none noted and that the resident's representative and attending physician were contacted regarding the incident. 4. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of paranoid schizophrenia and bipolar disorder. Review of the MDS dated [DATE] revealed Resident #28 was moderately cognitively impaired and independent with activities of daily living. Review of nurse progress note dated 10/22/18 at 4:30 P.M. revealed staff witnessed Resident #28 punch another resident (Resident #54) in the face. Further review of the nurse progress revealed Resident #28 was assessed for injuries with none noted and that the resident's representative and attending physician were contacted regarding the incident. Further review of the progress note indicated Resident #28 reported she punched Resident #54 because she felt like it. Review of SRI's for the month of 10/2018 revealed no allegations of physical abuse were reported involving Residents #28 or #54. Interview with LPN #65 on 10/31/18 at 10:29 A.M. confirmed LPN #65 witnessed Resident #28 punch Resident #54 in the right side of the face on 10/22/18 at approximately 4:30 P.M. LPN #65 confirmed both residents were assessed for injuries with none noted, both residents' attending physicians and representatives were notified of the incident, and Resident #28 was placed on one on one supervision immediately following the incident. LPN #65 also confirmed Resident #28 told her she had punched Resident #54 because she felt like it. LPN #65 confirmed she notified the DON of the incident immediately thereafter. Interview with the DON on 10/31/18 at 10:34 A.M. confirmed LPN #65 had provided notification on 10/22/18 of Resident #28 punching Resident #54 in the face. The DON also confirmed she notified the Administrator of the incident on 10/22/18. Interview with the Administrator on 10/31/18 at 11:19 A.M. confirmed the DON had notified him on 10/22/18 that Resident #28 had punched Resident #54. The Administrator confirmed the incident involving possible physical abuse between Residents #28 and #54 had not been investigated or reported to the state agency, because the residents involved were not injured and he didn't believe that Resident #28 had an intent to injure Resident #54. Review of the facility's Abuse Prohibition, Investigation and Reporting policy dated 12/2017 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 4 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed reports of alleged abuse will be immediately reported to the Administrator and thoroughly invested. Further review of the policy revealed allegations of abuse will be reported to the state regulatory agency as required by state and federal law. Based on record review, interviews, review of facility Self-Reported Incidents (SRI's) and review of facility policy the facility failed to ensure allegations of resident to resident physical abuse were reported to the State Survey Agency within 24 hours after the allegation was discovered. This affected four Residents (#28, #54, #92 and #110) of four reviewed for abuse. The facility census was 124. Findings include: 1. Record review revealed Resident #92 was admitted to the facility on [DATE] with the following diagnoses; hypertension, dysphagia, muscle weakness, vascular dementia with behavioral disturbance, irritable bowel syndrome without diarrhea, and abnormal findings of blood chemistry. Review of Resident #92's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Resident #92 was reported to exhibit behaviors not directed towards others. Review of Resident #92's progress note dated 09/13/18 revealed the resident received physical aggression from another resident at lunch. Further review of the progress note revealed the residents were separated and Resident #92's physician and resident representative were notified of the incident. Resident #92 did not have any visible injuries as a result of the incident and the facility's supervisor was notified. 2. Record review revealed Resident #110 was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, malignant neoplasm of frontal lobe, type one diabetes mellitus, epilepsy, mood disorder and hypothyroidism. Review of Resident #110's annual (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility. Resident #110 also required extensive assistance with transfers, dressing, toileting and personal hygiene and supervision with eating on the 09/14/18 MDS. Resident #110 was reported to have behaviors directed towards others, verbal behaviors and behaviors not directed towards others on the 09/14/18 MDS. Review of Resident #110's progress note dated 09/13/18 revealed the resident pulled another resident's hair with her hands at lunch. Further review of the progress note revealed the residents were separated and Resident #110's physician and the facility's supervisor were notified of the incident Review of the facility's SRI's on 10/30/18 revealed there was no SRI completed for the incident between Resident #110 and Resident #92 on 09/13/18. Interview with Licensed Practical Nurse (LPN) #183 on 10/31/18 at 10:30 A.M. revealed she did not remember the altercation between Resident #110 and #92 on 09/13/18. LPN #183 stated the incident happened because she documented it in the medical record. LPN #183 also reported residents that have altercations were immediately separated and redirected. Interview with the Director of Nursing (DON) on 10/31/18 at 1:46 P.M. revealed the DON was made aware of the incident when Resident #110 pulled Resident #92's hair on 09/13/18. The DON reported she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 5 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 notified the Administrator of the incident and the residents were immediately separated. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 11/01/18 at 7:32 A.M. verified that a SRI and an investigation were not completed after Resident #110 pulled Resident #92's hair on 09/13/18. The Administrator stated he did not do a SRI or an investigation of the incident on 09/13/18 due to the incident being witnessed, a history of both residents having dementia and no injuries resulted from the incident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 6 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #54 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance and anxiety disorder. Residents Affected - Few Review of the MDS dated [DATE] revealed Resident #54 was cognitively intact and required assistance with activities of daily living. Review of nurse progress note dated 10/22/18 at 4:30 P.M. for revealed staff witnessed another resident (Resident #28) punch Resident #54 in the face. Further review of the nurse progress revealed Resident #54 was assessed for injuries with none noted and that the resident's representative and attending physician were contacted regarding the incident. 4. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of paranoid schizophrenia and bipolar disorder. Review of the MDS dated [DATE] revealed Resident #28 was moderately cognitively impaired and independent with activities of daily living. Review of nurse progress note dated 10/22/18 at 4:30 P.M. revealed staff witnessed Resident #28 punch another resident (Resident #54) in the face. Further review of the nurse progress revealed Resident #28 was assessed for injuries with none noted and that the resident's representative and attending physician were contacted regarding the incident. Further review of the progress note indicated Resident #28 reported she punched Resident #54 because she felt like it. Review of SRI's for the month of 10/2018 revealed no allegations of physical abuse were reported involving Residents #28 or #54. Interview with LPN #65 on 10/31/18 at 10:29 A.M. confirmed LPN #65 witnessed Resident #28 punch Resident #54 in the right side of the face on 10/22/18 at approximately 4:30 P.M. LPN #65 confirmed both residents were assessed for injuries with none noted, both residents' attending physicians and representatives were notified of the incident, and Resident #28 was placed on one on one supervision immediately following the incident. LPN #65 also confirmed Resident #28 told her she had punched Resident #54 because she felt like it. LPN #65 confirmed she notified the DON of the incident immediately thereafter. Interview with the DON on 10/31/18 at 10:34 A.M. confirmed LPN #65 had provided notification on 10/22/18 of Resident #28 punching Resident #54 in the face. The DON also confirmed she notified the Administrator of the incident on 10/22/18. Interview with the Administrator on 10/31/18 at 11:19 A.M. confirmed the DON had notified him on 10/22/18 that Resident #28 had punched Resident #54. The Administrator confirmed the incident involving possible physical abuse between Residents #28 and #54 had not been investigated or reported to the state agency, because the residents involved were not injured and he didn't believe that Resident #28 had an intent to injure Resident #54. Review of the facility's Abuse Prohibition, Investigation and Reporting policy dated 12/2017 revealed reports of alleged abuse will be immediately reported to the Administrator and thoroughly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 7 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few invested. Further review of the policy revealed allegations of abuse will be reported to the state regulatory agency as required by state and federal law. Based on record review, interviews, review of facility Self-Reported Incidents (SRI's) and review of facility policy the facility failed to ensure allegations of resident to resident physical abuse were thoroughly investigated . This affected four Residents (#28, #54, #92 and #110) of four reviewed for abuse. The facility census was 124. Findings include: 1. Record review revealed Resident #92 was admitted to the facility on [DATE] with the following diagnoses; hypertension, dysphagia, muscle weakness, vascular dementia with behavioral disturbance, irritable bowel syndrome without diarrhea, and abnormal findings of blood chemistry. Review of Resident #92's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Resident #92 was reported to exhibit behaviors not directed towards others. Review of Resident #92's progress note dated 09/13/18 revealed the resident received physical aggression from another resident at lunch. Further review of the progress note revealed the residents were separated and Resident #92's physician and resident representative were notified of the incident. Resident #92 did not have any visible injuries as a result of the incident and the facility's supervisor was notified. 2. Record review revealed Resident #110 was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, malignant neoplasm of frontal lobe, type one diabetes mellitus, epilepsy, mood disorder and hypothyroidism. Review of Resident #110's annual (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility. Resident #110 also required extensive assistance with transfers, dressing, toileting and personal hygiene and supervision with eating on the 09/14/18 MDS. Resident #110 was reported to have behaviors directed towards others, verbal behaviors and behaviors not directed towards others on the 09/14/18 MDS. Review of Resident #110's progress note dated 09/13/18 revealed the resident pulled another resident's hair with her hands at lunch. Further review of the progress note revealed the residents were separated and Resident #110's physician and the facility's supervisor were notified of the incident Review of the facility's SRI's on 10/30/18 revealed there was no SRI completed for the incident between Resident #110 and Resident #92 on 09/13/18. Interview with Licensed Practical Nurse (LPN) #183 on 10/31/18 at 10:30 A.M. revealed she did not remember the altercation between Resident #110 and #92 on 09/13/18. LPN #183 stated the incident happened because she documented it in the medical record. LPN #183 also reported residents that have altercations were immediately separated and redirected. Interview with the Director of Nursing (DON) on 10/31/18 at 1:46 P.M. revealed the DON was made aware of the incident when Resident #110 pulled Resident #92's hair on 09/13/18. The DON reported she notified the Administrator of the incident and the residents were immediately separated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 8 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 11/01/18 at 7:32 A.M. verified that a SRI and an investigation were not completed after Resident #110 pulled Resident #92's hair on 09/13/18. The Administrator stated he did not do a SRI or an investigation of the incident on 09/13/18 due to the incident being witnessed, a history of both residents having dementia and no injuries resulted from the incident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 9 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed Resident #22 was admitted on [DATE] and readmitted on [DATE]. Diagnoses of atherosclerotic heart disease, seborrheic dermatitis, seizures, type 2 diabetes, hypertension, abnormalities of gait and mobility, muscle weakness, dysphagia, major depressive disorder, benign prostatic hyperplasia, Alzheimer's disease, hyperlipidemia obstructive sleep apnea and gastro-esophageal reflux disease. Review of the MDS) dated [DATE] revealed Resident #22 had severe cognitive impairment and required extensive assistance with eating, toileting and bed mobility and total dependence for personal hygiene, dressing and transfers, always incontinent of bowel and bladder. Further review of the medical record revealed Resident #22 was sent to the hospital on [DATE] due to hypoglycemia and was readmitted to the facility on [DATE]. During an interview with the DON on 11/01/18 at 10:52 A.M., she stated no bed hold notice was given Resident #22 since he was private pay. She verified the bed hold notice was not provided to this resident when he went to the hospital on [DATE]. Review of the policy titled Bed Hold and Return to Facility dated 12/2016 revealed the facility would provide written information to the resident or the resident's representative of the bed hold policy upon leaving for hospitalization or a therapeutic leave. Based on record review, staff interview, and policy review the facility failed to provide written notification of the facility bed hold policy to the resident or resident's representative upon transfer to the hospital. This affected three (#22, #83, #127) of five residents reviewed for hospitalizations. The facility census was 125. Findings include: 1. Review of the medical record revealed Resident #83 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included malignant neoplasm of upper lobe left lung, acute respiratory failure, and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #83 was cognitively intact and required supervision with activities of daily living. Review of the nurse progress notes dated 09/09/18 through 09/15/18 revealed Resident #83 was sent out to the hospital on [DATE] with respiratory distress and was admitted to the hospital with hyponatremia and hypokalemia. The resident was readmitted to the facility on [DATE]. Further review of the medical record revealed a notice of the bed hold hold policy signed by the resident on 09/17/18 for the hospital transfer that occurred on 09/09/18. Interview with the Director of Nurse (DON) on 10/31/18 at 10:21 A.M. confirmed the notice of the bed hold policy for Resident #83's hospital transfer on 09/09/18 was not provided timely. 2. Review of medical record for Resident #127 revealed an admission date of 07/23/18 with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 10 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 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 0625 readmission dated of 09/12/18. Diagnoses included fistula of the intestine and anxiety disorder. Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE] revealed Resident #127 was cognitively intact and required supervision with activities of daily living. Residents Affected - Few Review of nurse progress notes dated 09/11/18 through 09/12/18 revealed Resident #127 was sent out to the hospital on [DATE] and was admitted to the hospital with a diagnosis of pulmonary embolism. The resident was readmitted to the facility on [DATE]. Further review of the medical record revealed there was no written notice of the bed hold hold policy provided to the resident for the hospital transfer that occurred on 09/11/18. Interview with the DON on 11/01/18 at 11:00 A.M. confirmed the notice of the bed hold policy for Resident #127's hospital transfer on 09/11/18 was not provided upon transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 11 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to timely complete an admission minimum data set (MDS) within fourteen days of admission. This affected one resident (Resident #120) of twenty-five resident's reviewed for timeliness of completion of MDS. The facility census was 124. Findings include: Review of Resident #120's medical record revealed the resident was admitted on [DATE]. Diagnoses included spinal stenosis, chronic pain syndrome, major depressive disorder, and anxiety disorder. Review of the admission MDS dated [DATE] revealed Resident #120 was cognitively intact and was independent with transfer, bed mobility, dressing, toileting and eating. Further review of the admission MDS dated [DATE] revealed it was actually completed on 10/16/18 and transmitted on 10/19/18. Resident #120 was admitted on [DATE] and the MDS should have been completed on 10/14/18. Interview with MDS Coordinator #90 on 11/01/18 at 10:54 A.M. confirmed the MDS for Resident #120 was completed late. Interview with the Director of Nursing (DON) on 11/01/18 at 3:30 P.M. confirmed the expectation of the facility was the admission MDS was to be completed within 14 days of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 12 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review the facility failed to serve food without touching it with bare hands. This directly affected three Resident's (#27, #327 and #65) of three observed. It had the potential to affect 122 residents who received food prepared by the kitchen. The facility identified two Residents (#19 and #37) who did not receive food prepared by the kitchen. The facility census was 124. Findings include: Observation of the dining room in C and D hallway on 10/29/18 at 12:45 P.M. revealed Licensed Practical Nurse (LPN) #157 touched resident's food with her bare hands while assisting with set up for lunch. LPN #157 washed her hands, then she picked up a roll with her bare hands, applied butter to the roll and handed it to Resident #27. LPN #157 again washed her hands, picked up a second roll and handed the roll to Resident #327. LPN #157 washed her hands again, picked up a roll with her bare hands a third time, buttered the roll and handed the roll to Resident #65. Interview with LPN #157 on 10/29/18 at 1:10 P.M. confirmed touching the rolls for Residents #27, #65 and #327 with her bare hands. Interview with the Director of Nursing (DON) on 10/30/18 at 1:58 P.M. identified two Residents (#91 and #37) who do not receive food at the facility. The DON confirmed at no time should resident food be handled with bare hands. Review of food handling policy (no date) revealed no instruction related to touching resident food with bare hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 13 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 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 0917 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure residents in semi-private rooms had private closet space. This affected 97 (Resident #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #21, #22, #23, #24, #25, #26, #27, #29, #30, #31, #33, #34, #36, #37, #38, #42, #44, #45, #47, #48, #49, #50, #52, #53, #54, #55, #58, #60, #61, #62, #64, #65, #66, #67, #69, #70, #71, #73, #75, #76, #77, #79, #80, #81, #82, #84, #85, #86, #88, #89, #90, #91, #93, #94, #95, #96, #97, #98, #99, #100, #103, #104, #107, #108, #110, #111, #112, #113, #114, #115, #116, #117, #120, #121, #123, #124, #125, #143, #228 and #327) of 97 residents residing in semi-private rooms, identified by the facility. The census was 124. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with the following diagnoses; type 2 diabetes mellitus, hypothyroidism, chronic embolism and thrombosis of other specified veins, major depressive disorder, shortness of breath, generalized anxiety disorder, constipation and other muscle spasm. Review of Resident #53's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. Resident #53 also required supervision with eating. Interview with Resident #53 on 10/29/18 at 12:16 P.M. revealed the resident did not like her closet because it was too small and she had to share the closet with her roommate. Observation of Resident #53's room at the time of the interviews revealed there was only one closet in the resident's room. Resident #53's closet contained Resident #53 and Resident #2's clothing and personal items. Resident #53 and Resident #2's clothing was observed to be separated by a plastic ring connected to the clothes rack in the closet that was approximately 3.5 inches in diameter. The plastic ring was observed to be easily moved from side to side on the clothes rack. Resident #53's clothing was also observed to be taking up approximately 75 percent of the space on the clothing rack with Resident #2's clothing taking up approximately 25 percent of the space on the clothing rack. Resident #53 and Resident #2's clothing was observed to be in direct contact. The room did not contain a wardrobe or any additional type of closet space. Interview with the Administrator on 10/31/18 at 8:15 A.M. verified Resident #53 and Resident #2's room only had one shared closet. The Administrator also reported all semi private rooms in the facility had one closet for two residents to share and store their clothing. The Administrator also confirmed the facility did not have wardrobes or other forms of private closet space for residents. The Administrator reported he was not aware that residents were required to have private closet space with their clothing being kept separate from their roommates. The Administrator also stated clothing was separated in the shared closet using a plastic ring connected to the clothes rack. The Administrator verified the plastic ring could be easily moved and did not keep the resident's clothing from touching. The Administrator also confirmed the facility did not have a variance to allow the facility to have one shared closet per semi-private resident room. Review of the facility census revealed the facility to have 97 Residents (#1, #2, #3, #4, #5, #6, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 14 of 15 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 365443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Milford 934 State Route 28 Milford, OH 45150 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 0917 Level of Harm - Minimal harm or potential for actual harm #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #21, #22, #23, #24, #25, #26, #27, #29, #30, #31, #33, #34, #36, #37, #38, #42, #44, #45, #47, #48, #49, #50, #52, #53, #54, #55, #58, #60, #61, #62, #64, #65, #66, #67, #69, #70, #71, #73, #75, #76, #77, #79, #80, #81, #82, #84, #85, #86, #88, #89, #90, #91, #93, #94, #95, #96, #97, #98, #99, #100, #103, #104, #107, #108, #110, #111, #112, #113, #114, #115, #116, #117, #120, #121, #123, #124, #125, #143, #228 and #327) residing in semi-private rooms. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365443 If continuation sheet Page 15 of 15