Health inspection·October 20, 2025

F 0760 Level of Harm - Actual harm Residents Affected - Few #105's progress notes revealed the resident was sent out to the hospital on [DATE] for worsening of the pressure ulcer to his coccyx. The wound had an increase in size, an increase in pain, and an increase in purulent drainage with a foul odor. He returned to the facility on [DATE] on intravenous antibiotics and a new order for MS Contin 15 mg po twice a day for pain. He did not return with an order for the use of Lyrica 150 mg po three times a day that had been ordered prior to his transfer to the hospital on [DATE]. Review of a telehealth note dated 09/28/25 at 8:00 A.M. revealed the nurse practitioner was notified by nursing that Resident #105's previously prescribed Lyrica that was ordered at 150 mg po three times a day for neuropathy was not on the hospital's discharge summary upon his return to the facility on [DATE]. The resident was requesting his Lyrica to be re-instated for pain. An order was given for Lyrica 150 mg po three times a day to be given on a scheduled basis with directions to hold for sedation. Review of a nurse's progress note from registered nurse (RN) #100 on 09/30/25 at 4:45 P.M. revealed a nurse had alerted her that Resident #105 had confusion and was showing slight sedation effects. The resident was noted to be oriented to self and place when assessed by RN #100 with the following vital signs: Blood pressure 95/75, pulse 65 beats per minute, respirations at 17/ minute, and a temperature of 98 degrees Fahrenheit. The resident's oxygen level was normal at 95% on room air. The nurse reviewed the resident's medication and reported he received an extra dose of medication (not specified) and his extended-release medication (not specified) was given crushed with his other scheduled medications. The physician's assistant (PA) was notified immediately regarding the resident's current assessment findings and his reported vital signs. A new order was received to administer Narcan ((an opioid antagonist medication used to reverse or reduce the effects of opioids) 4 mg/ 0.1 milliliters (ml) nasal spray x 1 dose. Review of a nurse's progress note by RN #100 dated 09/30/25 at 4:51 P.M. revealed a new order was received to hold Resident #105's evening dose of MS Contin and Lyrica per an order from the PA. Resident #105 was re-assessed, and his blood pressure was 111/67, pulse 67, respirations of 17, and his oxygen level was 97% on room air. The resident was noted to be alert and oriented to person, place, time, and event. His wife that was visiting wanted him to go to ER to be assessed. The PA was notified and gave an order for the resident to be transferred to the ER for an evaluation as requested by the resident's family. It was deemed by the PA to be a non-emergent transport, due to the resident's current orientation, alertness, and ability to eat and drink. It was made known to the PA and the wife that the community's ambulette service could not transport the resident to the hospital for a couple of hours and both were in agreement that the resident did not need transported emergently and could wait for the ambulette to be available for transport. The resident returned to the facility on [DATE] at 2:10 A.M. in stable condition. He was alert and oriented upon his return and aroused/ responded appropriately. He did not return with any new orders. Review of Resident #105's medication administration record (MAR) for September 2025 revealed the resident was scheduled to receive his MS Contin 15 mg ER tablet po twice a day at 8:00 A.M. and 8:00 P.M. He received his dose of MS Contin 15 mg ER the morning of 09/30/25 at 8:00 A.M. He also received his ordered dose of Lyrica 150 mg at 8:00 A.M., as was ordered three times a day. Review of Resident #105's hospital records for his ER visit on 09/30/25 revealed they included an emergency department (ED) note dated 09/30/25 at 8:18 P.M. that indicated the resident's chief complaint was identified as presenting with a drug overdose. He was being evaluated for hallucinations and an altered mental status after receiving a crushed up Morphine ER tablet at the nursing facility according to his wife that accompanied him to the ER. Upon his arrival, the resident reported he was at his baseline and denied any current complaints. He requested to be sent back to the nursing facility at that time. His symptoms were likely due to receiving a crushed extended release (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365466 If continuation sheet Page 2 of 5 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 10/20/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few Morphine tablet as his symptoms were currently resolved. No medication changes were made as a result of his ER visit. Review of Resident #105's pharmacy label for the MS Contin (Morphine ER) 15 mg tablets revealed the label on a Controlled Drug Receipt/ Record/ Disposition form dated 09/28/25 included instructions to the nurse that read Do Not Crush, Chew, or Split the medication tablet. The label on the blister pack for the MS Contin 15 mg tablets also included the same instructions not to crush, chew, or split the tablets. Review of a Medication and Treatment Incident Report dated 09/30/25 (date of incident/ date discovered/ and date reported) completed by RN #100 revealed Resident #105 was given MS Contin ER oral tablet crushed, despite it being an extended-release tablet. The time of the incident was indicated to be 4:45 P.M. The medication error resulted in the need for medical treatment/ intervention, as the resident was given Narcan x 1. The medication error was determined to be the result of the nurse's failure to follow procedure. The corrective action taken included providing additional training and written counseling. The training provided involved crushable versus non-crushable medication. The nurse involved in the medication error was not identified by name on the incident report. The medication and treatment incident report did not mention anything about the resident receiving an extra dose of any medication, as was indicated in the progress note dated 09/30/25 at 4:45 P.M., only that his MS Contin had been given crushed with his other medications. Review of the nursing schedule for 09/30/25 revealed licensed practical nurse (LPN) #150 was the nurse assigned to work Resident #105's hall at the time the significant medication error occurred on the resident. Certified Nursing Assistant (CNA) #200 was one of three CNA's that was assigned to work Resident #105's hall when the medication error occurred. Review of the employee file for LPN #150 revealed he received a final written warning on 09/30/25, as a result of the significant medication error that he committed on Resident #105. The disciplinary action given with the final warning was for an infraction of work Rule # 20. A description of the reason for the disciplinary action indicated the nurse committed a medication error that resulted in a resident being sent to the ER to be evaluated following the error. Education was provided to the nurse on medications that could not be crushed, i.e. extended release medications. The nurse signed the disciplinary action report on 10/06/25. On 10/16/25 at 1:12 P.M., an interview with LPN #150 via phone confirmed he did work on 09/30/25, when Resident #105's medication error pertaining to his MS Contin and Lyrica occurred. He further confirmed he was the nurse that administered Resident #105's 8:00 A.M. medications to him. He indicated they just added a new medication for Resident #105's pain control, as his pain medication was changed to Morphine ER. He admitted to crushing the MS Contin (Morphine) ER tablet along with all other medications he gave to the resident that morning. He denied he was aware the MS Contin was not to be crushed. That was the first time he had worked with the resident, since the MS Contin had been ordered. He claimed he had interacted with the resident that entire day following the administration of his morning medications. He reported the resident had been having a change in his condition, as his overall health had been declining. He recalled the resident was pointing and speaking to things that were not there. He told the unit manager and documented his findings. He thought it was somewhere between 10:00 A.M. and 11:00 A.M., when that occurred. The unit manager told him she would call the resident's wife. The wife showed up at the facility later that day and was told the resident was having lots of problems. The wife asked if they had crushed the resident's medications. When told that they had, the wife informed him that the resident was receiving MS Contin XR that should not be crushed. He then reported it to the unit manager. He confirmed, after that incident, he was given a written warning, as a result of that significant medication error. He denied there was any instructions provided with the order for the MS Contin that directed them not to crush, when he gave the medication. He had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365466 If continuation sheet Page 3 of 5 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 10/20/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few since been educated on what medications could and could not be crushed. On 10/16/25 at 1:43 P.M., an interview with CNA #200 confirmed she was one of the three aides that worked on 09/30/25, when the medication error involving Resident #105 occurred. She was not aware that a medication error had occurred but did interact with the resident that day. She recalled the resident was very tired that day. She helped the nurse (LPN #150) do the resident's wound treatment that day around 3:00 P.M. or 3:30 P.M. She stated the resident was very confused and was not alert that day per his usual self. They also had to help feed him that day, as the resident was spilling food on himself. She too reported the resident's health had been declining and he was on hospice at that time. She recalled being at the nurses' station at the time when the resident's wife came in and was upset with how the resident was. She thought that was around 5:30 P.M. (towards the end of her shift), but then recalled they were passing meal trays around that time, so it could have been anywhere between 4:45 P.M. and 5:30 P.M. On 10/16/25 at 1:49 P.M., an interview with RN #100 revealed she was the unit manager for Resident #105's hall. She described Resident #105's normal mental status as being alert, but he could have some confusion at times. He was oriented to self and place. He was also known to be drowsy at times, due to the medications he took and his overall health status. She reported the nurse (LPN #150) came to her late in the afternoon of 09/30/25, and told her Resident #105 was not feeling good. She went to his room to assess him and found the resident to be drowsy and more confused than normal for him. She came back into her office to call the resident's provider to inform them of the resident's noted change in condition. LPN #150 then returned to her office and informed her that he crushed the resident's MS Contin and gave him too much Lyrica. She was asked to clarify the nurse's note she wrote that was dated 09/30/25 at 4:45 P.M., which indicated the resident received an extra dose of medication, in addition to his extended-release medication being crushed with other scheduled medications. She confirmed Resident #105 was also given double the dose of Lyrica (300 mg) that was ordered for him on 09/30/25 at 8:00 A.M. She confirmed he received 300 mg, when he should have only been given 150 mg as ordered three times a day. She indicated at the time, they had been giving the resident a 100 mg capsule and a 50 mg capsule of Lyrica to equal a total dose of 150 mg. They then received Lyrica 150 mg capsules from their pharmacy. LPN #150 had indicated to her that he gave Resident #105 a 100 mg capsule of Lyrica, a 50 mg capsule of Lyrica, and a 150 mg capsule of Lyrica equaling 300 mg (doubling his ordered dose). She was asked if the resident had been receiving his medications crushed, prior to the incident occurring on 09/30/25. They were giving him his medications whole in pudding, but at some point started crushing some of his medications due to him having some swallowing issues with the larger pills. She had heard other nurses inform the resident in the past that there were certain medications he received that they could not crush. She was not aware of any of the other nurses ever crushing his MS Contin, prior to or after the incident on 09/30/25. She was not aware of the nurse crushing all the resident's medications that morning and believed the resident had a standing order in place that they could crush allowable medications. She later reported that the standing order giving them permission to crush allowable medications had been inadvertently discontinued somewhere along the way and was not part of his current physician's orders. She was asked if extended release or delayed release medications could be crushed and she replied no. If there was a resident with those type of medications ordered that were having trouble swallowing the tablet or capsule, they should reach out to the physician to see about getting other similar medications ordered that could be given in a form the resident was able to safely take. She confirmed they provided education to the nurses following the occurrence of that medication error about being mindful to follow the instructions on medications' labels regarding those medications that could not be crushed. They have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365466 If continuation sheet Page 4 of 5 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 10/20/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete since placed a list of medications that should not be crushed on all units accessible to the nurses administering medications. LPN #150 was the one that administered Narcan to Resident #105, after she got the order when calling the provider. She stated within 60 seconds of receiving the Narcan, the resident was talking per his usual. He was alert, drinking, and eating supper. The wife wanted the resident sent to the ER, despite the resident saying he felt fine. They sent him to the ER as requested by the family and as agreed to by the resident. He returned a short time later with no new orders. On 10/16/25 at 2:10 P.M., an interview with facility's Director of Nursing (DON) revealed RN #100 was in the building when the medication error involving Resident #105 on 09/30/25 occurred. She was informed there had been a change in Resident #105's condition, which included confusion. When RN #100 was looking into the resident's change in condition, LPN #150 said Oh my God, I crushed his Morphine. RN #100 had reached out to the resident's provider and got an order for Narcan. Resident #105 had positive results to the Narcan and was back to his baseline. His wife wanted him sent out to the ER anyway. He was found to be at baseline when he was evaluated at the hospital. She confirmed she was the one that completed the medication error report the day after the medication error occurred. She spoke with the unit manager (RN #100), pulled the nurse's documentation, reviewed the progress notes, and talked with the PA, as part of her review. She stated they started crushing Resident #105's medications ever since he had thyroid surgery, but not all of his medications. She was not 100% sure if all his medications had been crushed that morning, or if it was just the MS Contin. She confirmed the MS Contin should not be crushed as it was an extended-release tablet and would result in the resident receiving an immediate dose of Morphine 15 mg instead of it being slowly released over a 12 hour period. Review of the facility's Medication Administration policy revised 10/17/23 revealed resident medications were to be administered in an accurate and safe manner. Medications were to be administered in accordance with written orders of the attending physician. The nurse was to check the Do Not Crush list before crushing medications. If necessary, the nurse was to contact the ordering physician for a change to a different route of administration when the medication could not be crushed. This deficiency represents non-compliance investigated under Complaint Number 2637682. Event ID: Facility ID: 365466 If continuation sheet Page 5 of 5