Health inspection·July 11, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #18 revealed the resident was admitted on [DATE]. Medical diagnoses included urinary tract infection, non-st elevation myocardial infarction, atherosclerotic heart disease, chronic obstructive pulmonary disease, type two diabetes mellitus, dysphagia oral phase, muscle weakness, hypertension, encephalopathy, psychosis, gastrointestinal hemorrhage, congestive heart failure and chronic kidney disease stage three. Review of Resident #18's admission MDS dated [DATE] revealed Resident #18's cognition was severely impaired. Continued review of Resident #18's medical record revealed Resident #18 was transferred to a local hospital on [DATE] due to a change in condition that required immediate medical care. Review of the medical record revealed a progress note that stated the transfer notice was given to the resident. Interview on 07/10/19 at 4:55 P.M. with Licensed Nursing Home Administrator (LNHA) who verified she had no documented evidence a copy of the transfer notice was sent to the responsible party for the transfer on 05/26/19 of Resident #18 as required. Based on record review and staff interview, the facility failed to ensure the resident's representative received written transfer/discharge notices when hospitalized . This affected two residents (Resident #24 and #18) of four resident's reviewed for hospitalization. The facility census was 48. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, heart failure and depression. Review of Resident #24's plan of care dated 04/18/19 revealed interventions including falls related to psychotropic drug use. The resident's plan of care did not have any interventions related to the diagnosis or behaviors associated with the resident's diagnosis of schizophrenia. The care plan additionally did not have any interventions related to the medication, Benztropine (anticholinergic) prescribed for tardive dyskinesia. Review of Resident #24's Minimum data set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of five, indicating severe cognitive impairment. The MDS additionally revealed the resident required extensive one-person assistance for bed mobility, transfers, dressing, and toileting. The resident required only set-up help with eating. Review of Resident #24's progress note dated 05/29/19, revealed the resident was transferred to an inpatient psychiatric care facility for evaluation and treatment. The resident was readmitted to the facility on [DATE]. Interview on 07/10/19 at 11:10 A.M. with Director of Nursing (DON) and Regional Clinical Coordinator (RCC) #300 confirmed Resident #24's representative was not provided a written notice of transfer/discharge when Resident #24 was transferred and admitted to the hospital on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 2 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 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 0641 Ensure each resident receives an accurate assessment. 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 and staff interview, the facility failed to ensure a resident's assessment was coded correctly. This affected one (Resident #23) reviewed of five residents reviewed during the review of Unnecessary Medication Review. The facility census was 48. Residents Affected - Few Findings include: Medical record review for Resident #23 revealed the resident was admitted on [DATE]. Medical diagnoses included but not limited to, muscle weakness, cognitive communication deficit, frontal lobe and executive function deficit, depression, bacterial infection, type two diabetes mellitus, hypertension, atrial fibrillation, heart failure, adult failure to thrive, dementia, Alzheimer's disease, and, dysphagia pharyngeal phase. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23's cognition was moderately impaired. Review of Resident #23's psychiatric physician note dated 05/28/19 revealed Resident #23 was taking Seroquel (antipsychotic) 25 milligrams (mg) by mouth at bedtime and one half tablet twice per day. Review of Resident #23's Medication Administration Record (MAR) for May 2019 revealed an order for Quetiapine Fumarate (Seroquel) 25 mg one tablet by mouth at bedtime with a start date of 04/27/19 and a discontinue date of 06/13/19. Review of Resident #23's May 2019 MAR revealed an order for Quetiapine Fumarate 25 mg one half tablet by mouth twice per day with a start date of 04/28/19 and a discontinue date of 07/09/19. Review of Resident #23's 05/09/19 significant change MDS assessment, section N0410 medications received during the seven day look back period revealed the resident had received antipsychotic medications during the seven day look back period for seven days. Review of Resident #23's 05/09/19 signficant change MDS assessment, section N0450 antipsychotic medication review was marked antipsychotics were not received. Interview on 07/10/19 at 4:39 P.M. with MDS #175 who verified Resident #23 received antipsychotic medication and the MDS was coded incorrectly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 3 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to timely complete a Preadmission Screening/Resident Review (PAS/RR) after a significant change. This affected one resident (Resident #24) of one resident reviewed for PAS/RR. The facility census was 48. Findings include: Review of Resident #24 medical record revealed being admitted on [DATE] with diagnoses including unspecified dementia, heart failure and depression. Review of Resident #24's PAS/RR dated 03/26/18 did not identify the resident had a diagnosis of schizophrenia. Review of Resident #24's plan of care dated 04/18/19 revealed interventions including falls related to psychotropic drug use. The resident's plan of care did not have any interventions related to the diagnosis or behaviors associated with the resident's diagnosis of schizophrenia. The care plan additionally did not have any interventions related to the medication, Benztropine (anticholinergic) prescribed for tardive dyskinesia. Review of Resident #24's Minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) of five, indicating severe cognitive impairment. MDS additionally revealed resident required extensive one-person assistance for bed mobility, transfer, dressing, toileting. Resident required only set-up help with eating. Review of Resident #24's progress note from 05/29/19 revealed the resident was transferred to an inpatient psychiatric care facility for evaluation and treatment and readmitted to the facility on [DATE]. Review of Resident #24's medical record revealed the resident received a diagnosis of schizophrenia on 07/01/18. Interview on 07/10/19 at 11:10 A.M., with the Director of Nursing (DON) and Regional Clinical Coordinator (RCC) #300 confirmed Resident #24 was given a diagnosis of schizophrenia on 07/01/18 and confirmed a significant change PASRR was not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 4 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents had a complete and accurate plan of care. This affected one resident (Resident #24) of sixteen residents reviewed. The facility census was 48. Findings include: Review of Resident #24 medical record revealed being admitted on [DATE] with diagnoses including unspecified dementia, heart failure and depression. Review of Resident #24's plan of care dated 04/18/19 revealed no interventions related to the diagnosis or behaviors associated with the resident's diagnosis of schizophrenia. The care plan additionally did not have any interventions related to the medication, Benztropine (anticholinergic) prescribed for tardive dyskinesia. Review of Resident #24's Minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) of five, indicating severe cognitive impairment. MDS additionally revealed resident required extensive one-person assistance for bed mobility, transfer, dressing, toileting. Resident required only set-up help with eating. Review of Resident #24's physician orders dated 06/15/19 revealed Benztropine 0.5 milligrams (mg.) by mouth with the diagnosis of tardive dyskinesia. Review of Resident #24's medical record revealed resident received a diagnosis of schizophrenia on 07/01/18. Interview on 07/10/19 at 11:10 A.M. with Director of Nursing (DON) and Regional Clinical Coordinator (RCC) #300 confirmed Resident #24 was given a new diagnosis of schizophrenia on 07/01/18. DON also confirmed Resident #24 was on Abilify (antipsychotic) for schizophrenia and depression. DON also confirmed Resident #24 was prescribed Benztropine (anticholinergic) for tardive dyskinesia on 06/15/19. DON confirmed Resident #24's most recent plan of care dated 04/18/19 did not reveal interventions related to tardive dyskinesia or behaviors related to the schizophrenia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 5 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to review and update the plan of care for two residents. This affected one (Resident #23) of five (#17, #19, #24 and #37) residents reviewed during the review of Unnecessary Medication Review and one (Resident #42) of 17 residents reviewed for dental concerns. The facility census was 48. Findings include: 1. Medical record review for Resident #23 revealed the resident was admitted on [DATE]. Medical diagnoses included muscle weakness, cognitive communication deficit, frontal lobe and executive function deficit, depression, bacterial infection, type two diabetes mellitus, hypertension, atrial fibrillation, heart failure, adult failure to thrive, dementia, Alzheimer's disease, and, dysphagia pharyngeal phase. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23's cognition was moderately impaired. Review of Resident #23's psychiatric physician note dated 05/28/19 revealed Resident #23 was taking Seroquel (antipsychotic) 25 milligrams (mg) by mouth at bedtime and one half tablet twice per day. Review of Resident #23's Medication Administration Record (MAR) for May 2019 revealed an order for Quetiapine Fumarate (Seroquel) 25 mg one tablet by mouth at bedtime with a start date of 04/27/19 and a discontinue date of 06/13/19. Review of Resident #23's May 2019 MAR revealed an order for Quetiapine Fumarate 25 mg one half tablet by mouth twice per day with a start date of 04/28/19 and a discontinue date of 07/09/19. Review of Resident #23's 05/09/19 significant change MDS assessment, section N0410 medications received during the seven day look back period revealed the resident had received antipsychotic medications during the seven day look back period for seven days. Interview on 07/10/19 at 4:39 P.M. with MDS #175 who verified Resident #23 received antipsychotic medication and the care plan did not include a care plan for the use of psychotropic medications and it should have. 2. Review of Resident #42's medical record revealed an admission date of 02/28/18 with diagnoses including Alzheimer's Disease, dysphagia (difficulty swallowing), and type two diabetes. Review of the nursing assessment dated [DATE] revealed the resident had a full set of upper and lower dentures upon admission. Review of Resident #42's care plan dated 06/20/19 revealed no interventions or information relating to oral health and dentures. Review of the comprehensive and quarterly assessments dated 03/08/19 and 06/07/19 revealed no dental concerns identified for Resident #42. Review of the dental consultation dated 07/23/18 revealed Resident #42 had full dentures but does (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 6 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not want to wear them and dentures were covered with calculus and needed to be cleaned professionally in a dental office. Resident #42 should not wear them unless that was done. Interview with Licensed Practical Nurse (LPN) #191 on 07/10/19 at 1:50 P.M. revealed that Resident #42 did have a full set of dentures but does not want to wear them because a dental consultation deemed she was not a candidate. Review of Residents #42's care plan dated 07/11/19 revealed dental interventions and oral hygiene services provided to the resident by the facility. Interview with the Director of Nursing (DON) on 07/11/19 at 02:28 P.M. confirmed the 07/11/19 care plan relating to oral care/dental and interventions were not on the previous care plans and had not been developed until 07/11/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 7 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure a physician's order was obtained for a self-releasing seatbelt. This affected one (Resident #35) of one resident reviewed for seatbelts. The facility census was 48. Residents Affected - Few Findings include: Medical record review for Resident #35 revealed an admission date of 05/05/19. Medical diagnoses included intestinal adhesions with partial obstruction, spinal stenosis, abnormalities of gait and mobility, lack of coordination, muscle weakness, cerebral palsy, dysphagia oropharyngeal phase, convulsions, type two diabetes, neuromuscular dysfunction of bladder, depression, restless leg syndrome, shortness of breathe and history of falling. Review of the 11/12/18 physical device evaluation assessment revealed a self-releasing seatbelt was checked. Reason for enable device use was marked as guest preference. Review of the 04/10/19 physical device evaluation assessment revealed a self-releasing seatbelt was checked. Reason for enable device use was marked as safety awareness. Review of the 06/09/19 quarterly Minimum Data Set (MDS) assessment revealed Resident #35's cognition was intact. Review of Resident #35's July 2019 physician's order did not reveal a physician's order for the self-releasing seat belt. Interview on 07/10/19 at 4:40 P.M. with MDS #175 verified the facility had a care plan in place, although not the greatest and most detailed, but did have the seatbelt included and it was due to safety, resident request, cerebral palsy and falls. MDS #175 verified they did not have a physician's order for the seatbelt for Resident #35 and he should have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 8 of 9 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 365552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Blanchester, The 839 East Cherry Street Blanchester, OH 45107 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 review of facility policy, the facility failed to properly store and date food items to prevent contamination and spoilage and failed to ensure proper sanitation of microwaves. This had the potential to affect all residents residing in the facility who receive meals from the kitchen with the exception of one resident (Resident #199). The facility census was 48, Findings include: Observation of the kitchen on 07/08/19 at 8:40 A.M., revealed opened and undated food items including: spaghetti noodles in a bag open to air and a bag of corn bread mix. Two packs of hot dog buns were dated 06/28/19 were observed. Examination of the inside of the microwave revealed a yellowish tan splatter covering the top. Interview with Dietary Manager (DM) #144 on 07/08/19 at 8:45 A.M., confirmed dry food items noted above were open and undated and the bread was beyond the expiration date. DM #144 further confirmed the microwave in the kitchen was not cleaned and stated she would clean it with lemon juice. Observation of the nutrition room in the 200 hallway on 07/08/19 at 9:00 A.M., revealed bread was dated 07/02/19, hamburger buns were dated 06/21/19, and Nepro (food supplement) was dated 07/01/19. Examination of the inside of the microwave revealed an opaque cream colored film covered the inside and smelled of burnt cheese with an area the size of quarter of a burnt cheese appearance substance in the center of the turnplate. Interview with Director of Nursing (DON) on 07/08/19 at 9:10 A.M., confirmed the above items were expired and the microwave was not clean. Additional interview with the DON on 07/10/19 at 1:13 P.M., confirmed there was one resident (Resident #199) who was NPO (nothing by mouth) and did not receive food from the kitchen. Review of the facility's policy titled Dry Storage and Supplies, undated, revealed opened boxes or cans shall be stored in resealed containers/food bags that are labeled and dated. Review of the facility's policy titled Microwave, undated, revealed the microwave shall be cleaned and sanitized at least once a day and as needed. Wipe microwave out after each use. Rinse well , spray or wipe with sanitizer, let air dry. Review of the facility's policy titledFood Storage Labeling and Dating dated 10/16 revealed the facility's procedure to label, date, and securely cover all pre-packed open containers . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 9 of 9