Inspection·March 10, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility's safe. Upon opening the safe there was no $1,000.00 cash to be retrieved. The Administrator was notified of the missing $1,000.00 cash and an investigation was initiated. Review of BOM #602's statement on [DATE] revealed Resident #135 had left a voicemail in either November or December from Resident #135 requesting BOM #602 to visit in her room. BOM #602 stated she went to Resident #135's room and Resident #135 requested to have the $1,000.00 cash returned. BOM #602 stated there had been a new letter completed indicating the $1,000.00 cash had been returned to Resident #135 and Resident #135's had signed this letter as acknowledgment of receiving the money. BOM #602 then gave the new letter to the receptionist #288 to upload into the electronic medical record for Resident #135. Review of Resident #135's spouse interview dated [DATE] revealed the $1,000.00 cash had been given to Resident #135 for pending dental services and Resident #135's spouse did not receive back the $1,000.00 after the cash had been initially given to Resident #135 (by the spouse). Review of Resident #135's POA statement dated [DATE] revealed she had no knowledge of Resident #135 having that amount of cash at the facility or that Resident #135's spouse had given that amount of money to Resident #135. The first time the POA was made aware of the $1,000.00 was when she came to collect Resident #135's personal belongings on [DATE]. Review of Receptionist #288 statement dated [DATE] revealed there was no recollection of receiving the new letter from BOM #602 indicating Resident #135 had received the $1,000.00 cash. Receptionist #288 indicated to the Administrator to look in the drawer of the BOM's desk to see if the letter may have been placed there. The only letter found in the drawer was the original letter dated [DATE]. Interview on 03/06//25 at 2:15 P.M. with the Administrator revealed on [DATE] she was notified of Resident #135's missing $1,000.00 which had been secured in the safe. The Administrator stated an investigation was immediately initiated, the police were notified per the facility's Abuse policy and procedures, and a Facility-Reported Incident was initiated. The Administrator stated during the facility's investigation there was not a second letter found or uploaded into the electronic medical record as indicated by BOM #602 and there were no receipts or a copy of receipts indicating the returned money to Resident #135. The signature of Resident #135 at the bottom of the original letter dated [DATE] could not be confirmed as an indication of when the $1,000.00 had been returned to Resident #135. The Administrator stated BOM #602 was not currently employed at the facility. Interview on [DATE] at 1:30 P.M. with the Administrator revealed the facility issued a check on [DATE] to Resident #135's POA to replace the missing $1,000.00 and the facility had ordered a new safe for the BOM's office due to the old safe having been opened by the use of a key and the Administrator was not able to locate and secure the keys that reportedly had been used to open the safe. The Administrator stated the only facility staff that will have the code for the new safe is the Administrator and the BOM. Interview on [DATE] at 1:55 P.M. with BOM #272 revealed the facility's best practice is to encourage the residents to open a trust account for any money brought into the facility instead of keeping cash in the safe for residents or the family is notified of the cash and is asked to pick the money up from the BOM office. The BOM stated there should be a receipt completed and signed by the resident or the family indicating when money was received and/or returned. Observation on [DATE] at 2:00 P.M. revealed a new safe in the corner of the BOM's office. The new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365466 If continuation sheet Page 2 of 4 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 365466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Heath 717 South 30th Street Heath, OH 43056 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 0602 safe required a code to be entered when accessing the safe. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Resident Trust dated [DATE] revealed, Resident funds are only to be held in the resident trust account. It is prohibited for any facility representative to maintain or keep any funds for residents. All withdrawals are entered into Point Click Care, a receipt will be generated for the resident to sign and maintained in the month end folder. The resident will be given a copy of the signed receipt. Residents Affected - Few The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: - On [DATE] the Regional BOM audited current resident's trust funds reviewed for accuracy for [DATE], [DATE] and February 2025. There were no discrepancies. - On [DATE] the Administrator interviewed six random residents for any missing personal belongings and/or money. There were no discrepancies. - On [DATE] the Administrator educated Nursing Administration, Receptionist, and the BOM on resident money being placed in a trust account and not in the safe. - On [DATE] the Administrator educated all staff on the facility's abuse and misappropriation policy and procedures. - On [DATE] the Administrator issued a check for the $,1000.00 to Resident #135's POA. This deficiency represents non-compliance investigated under Complaint Number OH00161310. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365466 If continuation sheet Page 3 of 4 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 365466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Heath 717 South 30th Street Heath, OH 43056 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 medical record review, interviews and facility policy review the facility failed to ensure respiratory equipment used for sleep apnea, continuous positive airway pressure (CPAP), mask and tubing were cleaned routinely. This affected one resident (Resident #133) of three residents reviewed for use of respiratory care. The facility census was 128. Residents Affected - Few Findings Include: Review of Resident #133's medical record revealed admission date 09/15/22 and discharge date [DATE] with diagnoses including but not limited to unspecified dementia, spina bifida, sleep apnea, depression and anxiety. Resident #133 required staff assistance to complete activities of daily living (ADL) tasks related to having bilateral lower extremity impairment and used a wheelchair for mobility. Resident #133 had moderate cognitive impairment with a brief interview mental status (BIMS) score of 13 out of a possible 15 and Resident #133 used oxygen therapy and used a non-invasive ventilator (CPAP) for breathing assistance while sleeping. dated 10/04/24. Review of Resident #133's care plan dated 02/24/20 (continued from a prior admission) revealed Resident #133 was at potential risk for difficulty breathing with inventions including the use of a CPAP related to having sleep apnea. Review of Resident #133's signed physician orders revealed an order dated 06/19/20 for the use of CPAP every bedtime (HS) and as needed (PRN) for sleep apnea. Further review revealed there were no orders for routine cleaning of the CPAP facemask and tubing for Resident #133. Review of Resident #133's treatment administration record (TAR) dated 12/01/24 to 12/31/24 revealed the order dated 06/19/20 for the use of CPAP every bedtime (HS) and as needed (PRN) for sleep apnea was documented as completed every night shift. There were no orders documented as completed for the routine cleaning of the CPAP facemask and tubing. Interview on 03/06/25 at 10:20 A.M. with Licensed Practical Nurse (LPN) #428 revealed depending on which unit the resident resides on determines which staff cleans the respiratory equipment including facemask and tubing. If the resident resides on the ventilator unit the respiratory technician is responsible for cleaning the respiratory equipment, but if the resident resides on the other units then the nurses are responsible for cleaning the respiratory equipment on a daily routine basis. Resident #133 did not reside on the ventilator unit, therefore the nurses should have been cleaning his respiratory equipment. Interview on 03/10/25 at 2:00 PM with the Regional Registered Nurse (RRN) #610 confirmed Resident #133 did not have a physician's order for routine cleaning of the CPAP facemask and tubing when not in use. RRN #610 stated there should have been orders implemented for the routine cleaning of the CPAP facemask and tubing completed by the nurse. Review of the facility's policy titled, Use of Oxygen dated 02/28/25 revealed, The oxygen equipment should be cleaned regularly. This deficiency represents non-compliance investigated under Complaint Number OH00161310. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365466 If continuation sheet Page 4 of 4