Health inspection·April 26, 2021

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of an annual nutrition note by Registered Dietitian (RD) #110 dated 04/19/21, revealed the dietitian was aware of the resident's weight loss over the past 180 days and noted the resident was on a regular diet with fortified cereal with breakfast, was taking 25% - 50% of her meals, was assisted at her meals as needed/tolerated, and was accepting of her supplements. RD #110 noted the resident's current diet was appropriate to meet her estimated nutritional needs. She documented the resident's advancing dementia could impact her appetite and thus her weights, and the resident was offered supplements in between her meals to help meet her needs. Observation of the resident on 04/19/21 at 5:27 P.M. through 5:40 P.M., revealed the resident sitting up in bed with a meal tray in front of her. No staff were present in the room, or observed to offer feeding assistance or cueing during the meal period. The resident was drinking her lemonade, and eating a few lima beans and diced pears with her fingers. At some point during the meal the resident stirred her pat of margarine into her pears and was trying to stab at the pears with the wrong end of the fork. By the end of the meal period the resident had consumed a few lima beans, most of the diced pears, and her lemonade. At 5:45 P.M., State Tested Nurse Aide (STNA) #23 removed the resident's tray from the room without offering to assist the resident. Interview on 04/19/21 at 5:45 P.M., with STNA #23 verified the resident consumed less than 25% of her meal, and stated the resident prefers sweets, and the resident's family brings her in snack cakes to eat. Observation of the resident during the the evening meal on 04/20/21 at 5:36 P.M., revealed the resident sitting up in bed with her meal tray sitting on her over bed table. The resident was not eating anything on her main plate, but was eating part of a piece of cake, her water and lemonade. No feeding assistance or cueing was observed offered to the resident during the meal period. Interview with STNA #23 on 04/20/21 at 5:38 P.M., revealed he was assigned to care for the resident. STNA #23 was asked if the resident would allow staff to assist her with eating. The nurse aide reported that she would a little. When asked if he had tried to feed her recently, he stated that he had not tried to feed her this week, but did last week and she let him feed her a little bit. Observation of the resident's meal tray on 04/20/21 at 5:46 P.M., revealed the resident had consumed only about 1/2 the cake and her fluids. STNA #23 affirmed the resident ate less that 25% of the meal served. Observation of the resident on 04/21/21 at 8:33 A.M., revealed that Social Services staff (SS) #93 was feeding Resident #16 her breakfast. She shared she was also an STNA and helps with the resident's when needed. She reported the resident ate pretty well when she assisted her with eating, and the resident was eating well this morning, that she was really hungry. Interview with LPN #80 on 04/21/21 at 4:40 P.M., revealed the resident did need to be fed. She explained that sometimes the resident will feed herself more than other times but assistance is needed for the resident to finish her meals. LPN #80 stated some days the resident does better than others with eating, and will let you know when she is finished. Interview with STNA #30 on 04/22/21 at 10:28 A.M., regarding the resident's self-feeding abilities and level of assistance/supervision needed revealed the resident need her tray setup and you needed to get her started. She explained that you then need to come back during the meal to redirect the resident to eating, and encourage and cue her to eat but then will eat well. STNA #30 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident gets distracted during the meal and starts doing other things, and needs reminders to eat during the meal. 2. Review of Resident #22's medical record revealed an admission date of 08/21/19, with diagnoses including: malignant neoplasm of unspecified part of right bronchus 02/22/21, dysphagia oropharyngeal phase, schizoaffective disorders, major depressive disorder, muscle wasting and atrophy, and COVID-19 12/18/20, during stay. Review of a quarterly MDS assessment for the resident dated 01/19/21 revealed the resident had severe cognitive impairment, and required the extensive assistance of one staff for bed mobility, transfer, toilet use, and personal hygiene. The resident was assessed as having no behaviors, including rejection of care. Review of a comparison MDS assessment for the resident dated 12/23/20 revealed identified the resident's self-performance of personal hygiene as requiring only supervision with the assistance of one staff person. The assessment indicated the resident's ability to self-perform personal hygiene tasks changed from requiring supervision, to extensive assistance from the 12/23/20 MDS to the 01/19/21 MDS. Review of the resident's current comprehensive plan of care revealed a plan of care to address the resident's problem/need of being at risk for infection, pain or bleeding in the oral cavity as the resident had oral/dental health problems likely related to some carious, and missing teeth. The goal was for the resident to be free of infection, pain or bleeding in the oral cavity through the next review date. Interventions included, but were no limited to, providing/assisting/encouraging oral hygiene per protocol. In addition, the resident had a current comprehensive plan of care related to the resident's ADL self care performance deficit and requiring assistance with ADLs and mobility. The goal was for the resident to maintain his current level of function with ADLs including person hygiene. Interventions included, but were not limited to, observed/document/report to nurse as needed any changes in ADL ability, any potential for improvement, or reasons for inability to perform ADLs, keep finger nails trimmed an clean. There was no care plan evident for Resident #22 refusing care. Observation of the resident on 04/20/21 at 8:59 A.M., revealed the resident lying in bed with his eyes crusted in matter, his beard had food in it, his glasses were dirty, and his nails jagged with sharp edges. There was dark matter under his nails. Observation of the resident on 04/20/21 at 3:27 P.M., revealed the resident lying in bed. His beard and mouth were soiled, and when asked if got a shower today or was wanting a shower he stated no. The resident's glasses were clean at this time, and the resident verified someone cleaned them this morning but could not recall who. Interview with STNA #16 on 04/20/21 at 3:57 P.M., revealed she was the nurse aide who was assigned to care for the resident during the day shift. When observing the resident with the surveyor she affirmed the resident's nails were jagged and dirty and needed trimmed. STNA #16 reported nails are usually trimmed on shower days which for the resident with Tuesdays and Fridays during the night shift of duty. Regarding the resident's beard she shared the resident would let you wash it with a wash cloth but not let you trim it. STNA #16 affirmed the resident's eyes were crusted with matter and his eyeglasses were soiled but he let her clean his eyes and glasses this morning. She stated she could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 not get the resident to brush his own teeth, or let her brush his teeth. Level of Harm - Minimal harm or potential for actual harm Interview with Registered Nurse (RN) #69 on 04/26/21 at 10:54 A.M., revealed he has worked with Resident #22 for a while. He stated the resident was not accepting of ADLs and had a history of refusing showers. RN #69 affirmed the resident's oral care was less than acceptable, and verified the resident mouth emitted an unpleasant odor. When questioned if the the resident would accept a toothbrush or toothette in lieu of a toothbrush he was unsure, and stated he would ask one of the nurse aides. Residents Affected - Few Interview with STNA #19 on 04/26/21 at 11:05 A.M., reported she was familiar with the resident, but was assigned to the opposite end of the hall that day, but would check and change the resident's incontinence brief when needed. She asked if the resident had a toothbrush in his room, the nurse aide asked the resident if it was okay if she looked. STNA #19 checked the resident's bathroom, and drawers and found an empty toothbrush container and a small tube of toothpaste but no toothbrush. She affirmed she looked in all the places where the toothbrush might be kept/stored and found none. Interview with STNA #34 on 04/26/21 at 11:08 A.M., regarding the resident's ADLs acceptance and if she had brushed his teeth this morning, or set the resident up to brush his own teeth. She stated she has offered the resident toothbrush before but he declines, but he did let her washing his face and clean him up last week. When asked is she had offered to brush his teeth, or assist him in brushing his own teeth this morning, she stated she did not that there were things that she needed to catch upon this morning from last night. Review of the resident's electronic health record regarding ADLs care documentation from 03/28/21 through 04/26/21 indicated the resident was provided with all ADL care, with no refusals. Review of the electronic health record documentation for ADLs for 04/20/21 at 6:40 A.M. and 6:59 P.M., and 04/26/21 at 9:26 A.M., indicated the resident received/participated in all routine ADL care including shaving and nail care as needed, oral care, washing face and hands, and hair care. Review of the facility's guidelines titled Resident Care guidelines revised on 10/2019 revealed the daily personal hygiene minimally included assisting or encouraging the resident with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care. The guidelines specified that any concerns would be reported to the nurse. This deficiency substantiates Complaint Number OH00112580. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and resident interviews, the facility failed to provide each resident with an ongoing program of individual activities, consistent with the comprehensive assessment, designed to meet their specific interests in order to promote psychosocial well-being. This affected one (#83) of four residents reviewed for activities. The facility census was 81. Residents Affected - Few Findings include: Review of Resident #83's medical record revealed an admission date of 03/18/21, with diagnoses including: diabetes mellitus type 2 with diabetic neuropathy, morbid obesity, injury of kidney, hypertension, chronic embolism and thrombosis, anxiety disorder, and major depressive disorder. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed the resident was alert and oriented, with good memory and recall. The resident required the physical assistance of two staff for bed mobility and transfer, and did not walk. Review of the resident's physician orders dated 03/18/21 revealed an order for the resident to participate in recreational activities as tolerated. Review of an activity assessment dated [DATE], completed by Activity Director (AD) #84, revealed AD #84 documented the resident enjoyed working on word puzzles as well as doing jig saw puzzles. Review of the resident's current comprehensive plan of care for Activities developed on 03/19/21 revealed an activity problem/need of the resident preferring to engage in activities independently in her room, but willing to attend programs as interested. The goal was for the resident to express satisfaction with levels/choices of independent and/or group activity programs upon interview by the next review date of 06/16/2. Interventions included, but were not limited to, providing the resident with materials for independent activities as desired. Observation of Resident #83 on 04/19/21 at 2:15 P.M., revealed the resident was laying in bed watching television in her room. There were no individual activity items noted in the room at the time. Interview at this time, revealed when asked if any staff had provided her with in room activities of interest, the resident responded that no activities had been offered to her that she could do on her own in her room. She shared that currently she was mostly bed bound and was being treated for pressure sores. The resident then stated she liked to work puzzle books like word find puzzles, and jig saw puzzles. She again denied that anyone had brought her any books, magazines, word find or other puzzles books since she arrived at the facility, and stated she has just been watching television since admission. Observation of the resident on 04/20/21 at 3:24 P.M., revealed the resident laying in bed on her back working on a word search puzzle book. She had an additional work search puzzle book lying on her over bed table. The resident explained that her family brought the puzzle books that day, along with her glasses. The resident then stated now I have something to do. She affirmed she had not had any puzzle books until today, and that she enjoys working the puzzles. Observations of the resident intermittently throughout the remainder of the afternoon revealed the resident continuously working on the word search puzzle book when not eating or sleeping. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of the resident intermittently throughout the day on 04/21/21 revealed the resident was working on the word find puzzles books when not eating or sleeping. Interview with AD #84 on 04/21/21 at 3:38 P.M., verified she was aware that a family member dropped some activity books off to the resident on 04/20/21. When asked if the facility had any word find or other puzzle books AD #84 stated they did and did have word search books and adult coloring pages available for residents. AD #84 reviewed the resident's activity participation logs in the electronic health records and affirmed there was no documentation of participation related to word searches in the past 30 days. AD #84 stated activities could have done a better job in getting her word search puzzles to work in her room. Observation of the resident during interview on 04/22/21 at 10:19 A.M., revealed the resident was in her room, lying in bed, working on adult coloring pages. She stated that a lady that worked here brought them to her. Observation of the resident during interview on 04/26/21 at 10:44 A.M., revealed the resident was in her room in, lying in bed, coloring in a coloring book. There was a box of crayons and a box of colored pencils on her over bed table. The resident was highly involved in the activity. The resident again verified she did not have any work puzzles or coloring pages/books until last week (04/20/21) when her family first brought in the word find puzzle books. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, staff interviews, review of facility policy, the facility failed to accurately document pressure ulcer treatments and accurately document resident's pressure ulcers. This affected two (#16 and #21) of five residents reviewed for pressure ulcers. The census was 81. Residents Affected - Few Findings include: 1. Review of Resident #16's medical record revealed an admission date of 05/02/19. Diagnoses listed included altered mental status, aphasia, anxiety disorder, hypertension, hyperlipidemia, insomnia, muscle weakness, and major depressive disorder. Resident #16 was assessed as requiring extensive of assistance of two staff members for activities of daily living (ADL), not having a pressure ulcer, and being cognitively intact. Review of wound evaluation notes dated 02/16/21 revealed Resident #16 had a new in-house acquired stage III pressure ulcer to the coccyx measuring 1.02 centimeters (cm) x 0.87 cm x 0.1 cm. Review of physician orders revealed an order dated 02/19/21 for cleanse buttocks with normal saline, pat dry, apply calcium alginate (absorbent wound dressing), and cover with bordered gauze every day shift for wounds. Review of wound care nurse practitioner (NP) progress notes dated 02/23/21 revealed Resident #16's stage III had resolved. Review of treatment administration records (TAR) from 02/01/21 through 04/20/21 revealed pressure ulcer treatment had been completed as ordered since 02/20/21. Treatment was last documented as being completed on 04/20/21. Further review of weekly skin assessments and nurses progress notes from 02/23/21 through 04/20/21 revealed no documentation of any new pressure ulcer concerns. Interview with Registered Nurse (RN) #60 on 04/21/21 at 8:02 A.M., revealed Resident #16 no longer had a pressure ulcer. Resident #16 had a pressure ulcer for about week, then it resolved. RN #60 rounds with the wound care Nurse Practitioner (NP). Follow-up interview with RN #60 on 04/21/21 at 8:55 A.M., revealed he had observed Resident #16's coccyx and a treatment was found in place. A bordered gauze was removed. There was not any calcium alginate in place. When the treatment was removed, no open areas were discovered. RN #60 stated he must have forgotten to discontinue Resident #16's pressure ulcer treatment. Observation of Resident #16's sacrum on 04/21/21 at 10:34 A.M., revealed an open area with a dark wound base. A wound treatment was not in place. Observation of wound treatment to Resident #16 on 04/21/21 at 10:52 A.M., revealed a circular pressure ulcer to the sacrum measuring 1.0 centimeters (cm) x 0.5 cm x unable to be determined (UTD). RN #60 stated during the observation that Resident #16's wound would be staged by the wound care NP during her rounds the next week. RN #60 confirmed Resident #16's coccyx pressure ulcer was present when he removed a treatment he found in place the morning of 04/21/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a progress note dated 04/21/21 at 11:20 A.M., revealed the wound team was into review Resident #16. Resident #16 was noted with area to sacrum measuring 1 cm x 0.5 cm x UTD. Wound NP was contacted and an order for cleanse with normal saline (NS), pat dry, apply wound gel, and cover with foam every day and as needed (PRN). Family was notified. 2. Review of Resident #21's medical record revealed an admission date of 08/02/19. Diagnoses listed included atrial fibrillation, hyperlipidemia, hypertension, generalized anxiety disorder, weakness, major depressive disorders, and coronary artery disease. Resident #21 was assessed requiring assistance of two staff members for activities of daily living (ADL), having one unhealed stage II pressure ulcer, and being cognitively intact in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Review of skin/wound progress notes and weekly skin and wound evaluation form 12/01/20 through 04/20/21 revealed a stage II pressure ulcer to Resident #21's sacrum was first discovered on 12/31/20. Review of a skin/wound progress noted dates 12/30/20 at 3:30 A.M., revealed Resident #21 was noticed with red, superficial open area to sacrum, surrounding skin is very dry. Area with scant-red drainage. Area measured 2 cm x 0.9 cm x less than 0.1 cm. Resident #21 also noticed with heels to be fragile and red. New order to apply skin prep (preventative barrier liquid) every shift to heels, and keep off bed. Patient informed. Further review of weekly skin and wound evaluations dated 01/05/21, 01/12/21, 01/19/21, 01/26/21, 02/02/21, 02/09/21, 02/16/21, 02/23/21, 03/09/21, and 03/23/21 revealed Resident #21's stage II pressure ulcer was documented as being present for one week on all the evaluations. An exact date of of when the pressure ulcer was discovered was not given. Review of nurses noted dated 03/23/21 at 4:37 P.M., revealed the wound team observed Resident #21 to review coccyx wound. Coccyx wound is stable a 1 cm x 0.5 cm x 0.1 cm, and a second wound on the left buttocks of 1.4 cm x 1.1 cm x 0.1 cm, continue treatment of cleansing with normal saline, apply calcium alginate, and cover with border foam. Family and physician updated on status of wounds. Review of physician orders revealed an order dated 03/23/21 for cleanse left buttock area with normal saline, apply calcium alginate, and cover with border gauze daily and every shift PRN (as needed). Review or Treatment Administration Record (TAR) revealed a treatment to left buttock area had been documented as being completed from 03/24/21 through 04/20/21. Review of nurses notes and wound care NP notes dated 03/30/21 revealed Resident #21 coccyx wound was stable and measured 0.3 cm x 1 cm x 0.1 cm and second wound on left buttocks had resolved. Wound treatment of of cleansing with normal saline, apply calcium alginate, and cover with border foam. Family and physician were updated on status of wounds. Review of wound care NP notes dated 04/20/21 revealed wound team observed Resident #21 to review coccyx wound. Coccyx wound is stable at 0.35 cm x 0.1 cm x 0.1 cm. Continue treatment of cleansing with normal saline, apply calcium alginate and cover with border foam. Further review revealed no documentation of a left buttocks wound. Observation of Resident #21's pressure ulcer treatment on 04/21/21 at 10:15 A.M. revealed one bordered foam gauze with calcium alginate was in place to the coccyx. Further observation revealed one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unhealed superficial pressure ulcer to coccyx. There was not a treatment in place to left buttocks and a left buttocks pressure ulcer was not observed. Interview with RN #60 on 04/21/21 at 10:30 A.M., revealed Resident #21 had one pressure ulcer that had an area that healed in the middle that made two pressure ulcer areas. The second area then healed to one pressure ulcer area. RN #60 confirmed that two different pressure ulcer treatments were being documented as being completed. RN #60 confirmed the treatment to the left buttocks was not in place and that Resident #21 no longer had the left buttocks pressure ulcer. Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #98 on 04/21/21 at 4:00 P.M. confirmed the the concerns with in accurate wound treatment and wound assessment documentation for both Resident #16 and Resident #21. Review of the facility's policy titled Skin Management dated revised October 2019 revealed residents with wounds and/or pressure injury and those at risk for compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The licensed nurse will monitor, evaluate, and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, observations and staff interviews, the facility failed to ensure the medication error rate was below five percent. A total of 26 medications were observed administered with two medication errors, resulting in error rate of 7.69 percent. This affected two (#136 and #1) of two residents observed for medication administration. The facility census was 81. Residents Affected - Few Findings included: Observations on 04/21/21 at 9:35 A.M., of Licensed Practical Nurse (LPN) #80 administering medication to Resident #136, revealed LPN #80 administered Calcium 500 milligrams (mg) one tablet by mouth. Review of Resident #136's physician's orders revealed an order for Oscal 500/200 mg (Calcium Carbonate and Vitamin D) once daily. Observation was made on 04/21/21 at 10:10 A.M., of LPN #80 administering medication to Resident #1, revealed LPN #80 administered Calcium Citrate 200 mg. Review of Resident #1's physician's orders revealed an order for Calcium Citrate and D3, 315-250 mg (Calcium Citrate with Vitamin D) to give one tablet twice daily. Interview on 04/21/21 04:33 P.M., with the Assistant Director of Nursing (ADON) and LPN #80, verified the medications were not Administered as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, staff and resident interviews, the facility failed to assist a resident in obtaining routine dental care. This affected one (#26) of four residents reviewed for dental services. The facility census was 81. Residents Affected - Few Findings include: Review of Resident #26's medical record revealed an admission date of 01/03/20, with diagnoses including acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type 2, obesity, iron deficiency anemia, congestive heart failure, and dementia without behavioral disturbances. The resident was receiving Medicaid benefits. Review of a quarterly minimum data set assessment for the resident dated 01/21/21 revealed he had good memory and recall. He was not identified as having any oral/dental problems at that time. Review of the resident's current comprehensive plan of care revealed a problem/need which specified the resident was at risk for infection, pain or bleeding in the oral cavity. The goal for the resident was to be be free of infection, pain or bleeding in the oral cavity. Interventions included, but were no limited to, coordinating arrangements for dental care and transportation as needed/ordered, and obtaining a dental consult as needed. Review of of a consent form for ancillary services signed by the resident on 02/03/20 revealed the resident gave consent to receive all ancillary care services available to the resident including dental, vision, podiatry, and audiology. Review of the resident's electronic health record including nursing and social services progress notes failed to reveal any mention of the resident receiving any dental services since admission to the facility. Observation of the resident during interview on 04/19/21 at 4:51 P.M., revealed the resident had some missing and broken teeth. The resident stated I have pretty bad teeth and that he would like to see the dentist, and has not seen a dentist in years. He shared that he had asked the facility about seeing the dentist, but could not recall who he talked to about getting an appointment. The resident denied any oral/dental pain at that time. Interview with Receptionist #96 on 04/20/21 at 3:49 P.M., revealed that she was the staff person responsible for making appointments for residents needing to see the dentist, as well as other ancillary care services. She reported that nursing and other staff report to her what residents are requesting/needing to be seen and she puts them on the list for the next scheduled visit, unless it was an emergency. Interview with Receptionist #96 on 04/22/21 at 10:59 A.M., and 12:01 P.M., revealed the dentist was at the facility on 03/11/20, the 05/27/20 visit to the facility was canceled due to COVID-19, and the dentist returned to seeing residents at the facility on 04/09/21. She reported there were residents sent out for emergency dental services on 10/01/21 and 12/01/20. Receptionist #96 stated she checked with the dental service provider and affirmed Resident #26 was not on the list to be seen on either 03/11/20 or 04/09/21. She communicated she spoke with the coordinator for the contracted ancillary service provider who stated the dentist did not get the resident's physician order in time to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 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 0791 seen by the dentist. Receptionist #96 reported that did not make sense as the resident was seen by the audiologist on 04/06/21 from the contracted ancillary care service provider. 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: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, observations, staff interview, review of facility policies, and review of the facility legionella water prevention program, the facility failed to implement transmission based precautions for residents with Coronavirus (COVID-19) like symptoms. This affected four Residents (#8, #24, #46, and #72) and had the potential to affect all residents of the facility. The facility also failed to have a sufficient legionella prevention plan. This had the potential to affect all the residents of the facility. The facility also failed to ensure staff washed their hands when distributing meals to residents. This affected two (#1 and #37) residents observed during meals. The census was 81. Residents Affected - Many Findings include: 1. Review of Resident #8's medical record revealed an admission date of 08/14/14. Diagnoses listed included schizophrenia, aphasia, anxiety disorder, and hypertension. Further review revealed a physician order for contact and droplet precautions (transmission-based precautions) related to COVID-19 dated 04/16/21. Review of Resident #24's medical record revealed an admission date of 06/03/14. Diagnoses listed included bipolar disorder, schizophrenia, type II, diabetes mellitus, and hypertension. Further review revealed an order for contact and droplet precautions (transmission-based precautions) related to COVID-19 dated 04/16/21. Review of Resident #46's medical record revealed an admission date of 02/05/21. Diagnoses listed included psychotic disorder, schizophrenia, and hypertension. Further review revealed an order for contact and droplet precautions (transmission-based precautions) related to COVID-19 dated 04/16/21. Review of Resident #72's medical record revealed an admission date of 08/14/14. Diagnoses listed included schizophrenia, anxiety disorder, heart failure, and hypertension. Further review revealed an order for contact and droplet precautions (transmission-based precautions) related to COVID-19 dated 04/16/21. Observation of during tour on 04/20/21 at 7:58 A.M. through 9:00 A.M., revealed Resident #8, Resident #24, Resident #46, and Resident #72's room doors were marked with a sign to see nurse before entering. By each resident doorway was plastic drawer bin containing personal protective equipment (PPE). Observation of State Tested Nursing Assistant (STNA) #37 and STNA #40 on 04/20/21 from 8:00 A.M. to 8:50 A.M., revealed the staff entered the rooms of Resident #8 and Resident #46 to deliver breakfast trays and passed breakfast trays to Resident #8 and Resident #72 in the dining room. STNA #37 and STNA #40 did not don a gown, wear gloves, or have on a N95 respiratory mask when delivering trays to Resident #8, Resident #24, Resident #46, and Resident #72. Observation of Resident #24 and Resident #72 on 04/20/21 at 8:10 A.M. revealed they were eating breakfast together at a table in the common dining area in the secure behavioral unit. Observation at 04/20/21 at 8:34 A.M., revealed Licensed Practical Nurse (LPN) #70 checked Resident #24's blood pressure (BP) and oxygen saturation (SATS) in the hallway. LPN #70 was not wearing a gown or gloves. LPN #70 was wearing an earloops surgical mask and clear face shield. LPN #70 was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 wearing a N95 respirator mask. Level of Harm - Minimal harm or potential for actual harm Observation at 4/20/21 at 8:40 A.M., revealed LPN #70 administered medications to Resident #72 in the hallway. LPN #70 was not wearing a gown or gloves. LPN #70 was wearing an earloops surgical mask and clear face shield. LPN #70 was not wearing a N95 respirator mask. Residents Affected - Many Observation at 4/20/21 at 8:43 A.M. revealed LPN #70 checked SATS, checked BP, and checked Resident #72's finger stick blood sugar (FSBS) in the hallway. LPN #70 administered medications to Resident #72. LPN #70 was not wearing a gown. LPN #70 was wearing an earloops surgical mask and clear face shield. LPN #70 was not wearing a N95 respirator mask. Interview with Licensed Practical Nurse (LPN) #70 confirmed she had administered medications, checked BP, checked SATS, for Resident #24 and Resident #72, and checked FSBS for Resident #72 while in they were in they hallway. LPN #70 confirmed both Resident #72 and Resident #24 were currently in transmission-based precautions for COVID-19 like symptoms. LPN #70 confirmed she had not worn gown or a N95 respirator mask. Interview with STNA #37 and STNA #40 on 04/20/21 at 8:55 A.M., confirmed Resident #8, Resident #24, Resident #46, and Resident #72 were in transmission-based precautions. STNA #37 and STNA #40 confirmed they had not worn N95 respirator masks when delivering breakfast trays to Resident #8, Resident #24, Resident #46, and Resident #72. STNA #37 and STNA #40 confirmed Resident #24 and Resident #72 had eaten breakfast together in the dining room. Interview with LPN #98 on 04/22/21 at 9:10 A.M., confirmed Residents #8, Resident #24, Resident #46, and Resident #72 were in transmission-based precautions for COVID-19 like symptoms on 04/20/21. LPN #98 confirmed LPN #70 should not have checked BP, SATS, and administered medications to Resident #24 and Resident #72 while they were in the hallway on 04/20/21. LPN #98 confirmed LPN #70, STNA #37, and STNA #40 should have been wearing PPE required for transmission-based precautions for COVID-19. LPN #98 confirmed Resident #24 and Resident #72 should not have eaten breakfast in the dining room on 04/20/21. Review of the facility's policy titled Coronavirus (COVID 19) dated revised 03/31/21, revealed all recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or surgical if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and side of the face), gloves, and gown. 2. Review of the facility's Legionella Water Management Plan revealed water quality would be measured in different areas of the building. Water temperatures would be maintained and documented at the boiler and in the building. Shower heads and faucets would be kept clean and free of build-up. Ice machines would been cleaned and sanitized on a schedule on a schedule and documented. Further review revealed no documented parameters or schedule for water quality measurements or water temperatures. There was not a documented schedule for shower head and faucet cleaning or ice machine cleaning and sanitation. Review of facility legionella prevention plan documentation from 03/31/21 through 04/22/21 revealed no documentation of water quality measurements of any kind, no documented water temperature values or parameters, no documentation of shower head or faucet cleaning, and no documentation of ice machine cleaning or sanitation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 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 365457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Middletown 751 Kensington Street Middletown, OH 45044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview with Environmental Director (ED) #99 on 04/22/21 at 8:20 A.M., confirmed the legionella prevention plan was not sufficient. ED #99 confirmed there was no documentation of water quality measurements, water temperature values or parameters, shower head or faucet cleaning, and ice machine cleaning or sanitation. 3. Meal tray pass was observed on 04/19/21, at 12:16 P.M., on the 200 hall. Due to the COVID-19 pandemic status resident's were being served their trays in their respective room. Observations on 04/19/21, at 12:21 P.M., State Tested Nurse Aide (STNA) #23 was observed to take a meal tray into the room occupied by Residents #1 and #37. STNA #23 set Resident #1's meal tray down on his over bed table, cranked up his bed, and set-up the resident's meal tray by cutting food with the utensils and opening cartons. The STNA then left the room, and without washing hands or using alcohol based hand sanitizer, removed Resident #37's tray from the cart and took it into the room and set in on his over bed table on which the resident's urinal was also sitting. STNA #23 took a paper towel and picked the urinal up and moved it to the edge of the over bed table, cranked up the resident's bed, then set-up the tray for the resident and opening cartons/packages, left the room and went to the tray cart took another tray and headed down the hall to serve a resident. At no time during the observation was the STNA #23 observed to wash their hands or use an alcohol based hand sanitizer. Interview with STNA #23 on 04/19/21, at 12:32 P.M., verified the he did not use hand sanitizer or wash his hands when serving meal trays to the first few residents on the hall, and that there was no hand sanitizer in his pocket for quick use. He stated that staff were supposed to use hand sanitizer between each resident and wash his hands every few trays/rooms when passing out meal trays. The STNA then sanitized his hands with alcohol based hand sanitizer installed in the corridor. Interview with the Assistant Director of Nursing, Licensed Practical Nurse (LPN) #98 on 04/21/21 at 5:49 P.M., revealed that staff are instructed to be use hand sanitizer between serving each resident their meal tray, and then they are to wash their hands every third room. Review of the facility policy titled Hand Hygiene revised 09/2019 specified that if hands are not visibly soiled , use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other then those described in the handwashing section. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365457 If continuation sheet Page 15 of 15