Health inspection·April 18, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete and transmit a resident's discharge Minimum Data Set (MDS). This affected one (Resident #02) out of 14 residents reviewed for assessments. The facility census was 49. Residents Affected - Few Findings include: Review of the Resident #02's chart revealed Resident #02 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hypotension, type two diabetes mellitus, cerebral infarction, hypertensive heart disease with heart failure, sick sinus syndrome, unspecified atrial fibrillation, presence of cardiac pacemakers, delirium due to known physiological condition, acute kidney failure, and major depressive disorder. Resident #02 discharged from the facility on 12/19/21. Review of Resident #02's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severe cognitively impaired and Resident #02 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #02 also required supervision with eating on the MDS. Review of Resident #02's discharge Minimum Data Set (MDS) assessment dated [DATE] the MDS was in progress and was not transmitted. Interview with the Administrator on 04/13/22 at 8:43 A.M. verified Resident #02's discharge MDS was not completed or transmitted. Review of the facility's undated MDS policy revealed all portions of the resident assessment instrument will be completed according to the MDS 3.0 user manual or its most current version. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 2 of 13 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 04/18/2022 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the state mental health authority of a change in resident's mental health status. This affected one (Resident # 12) of two residents investigated for Preadmission Screening Resident Review (PASARR) during the annual survey. The facility census was 49. Findings include: Review of Resident # 12's medical record revealed an admission date of 11/24/17. Diagnoses included heart failure, metabolic encephalopathy, kidney failure, pericardial effusion, tobacco use, vitamin deficiency, and gastro-esophageal reflux disease. Review of PASARR dated 11/20/17 was silent in section D indicating Resident # 12 did not have any indications of serious mental illness. Review of Resident # 12's medical record revealed physician's progress note dated 08/30/2018 stating Prozac will be started for depressive symptoms. Further Review of Resident # 12's psychiatry progress notes dated 06/25/19, 10/18/19, and 12/11/19, revealed Resident # 12 reported depression, sleep disturbance, and memory loss. Review of Resident # 12's progress notes dated 01/21/20 and 01/22/20 state Resident # 12 having delusions and memory problems. Progress note dated 01/22/20 stated prazosin one milligram every day at bedtime was started for post-traumatic stress disorder. Progress note dated 01/23/20 described Resident # 12 having outbursts and delusions. Review of Resident # 12's medical record revealed she was transferred to Mercy Hospital [NAME] Emergency Department for Psychiatric Evaluation on 01/25/20. Further review of Resident # 12's medical record revealed an additional diagnosis of post-traumatic stress disorder was added on 01/24/20 and another additional diagnosis of major depressive disorder was added on 01/25/20. Interview with Administrator # 44 on 04/12/22 at 3:46 P.M. confirmed no other PASARR assessment had been completed for Resident # 12 since admission in 2017. The Assistant Director of Nursing # 83 stated the facility does not have a PASARR policy and the facility follows the regulations for PASARR assessments during interview on 04/14/22 at 12:10 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 3 of 13 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 04/18/2022 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 - Some 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** 4. Record review of Resident #41 revealed an admission date of 06/01/16 with pertinent diagnoses of: hemiplegia and hemiparesis following cerebral infarction, neuromscular dysfunction of the bladder, cerebral infarction, hypertensive heart disease, type two diabetes mellitus with diabetic chronic kidney disease, hyperlipidemia, iron deficiency anemia, retention of urine, dysphagia, benign prostatic hyperlplasia, depression, anxiety disorder, vascular dementia, vitamin D deficiency, cognitive communication deficit, and anhidrosis. Interview with Resident #41 on 04/11/22 at 8:30 P.M. revealed the Resident denied having any care conferences recently. Review of Resident #41 medical record on 04/13/22 revealed no documented instance of a care conference since 07/14/21. The Resident had quarterly Minimum Data Set (MDS) assessments on 10/07/2021,12/09/21, 03/11/22 and 03/31/22. Interview with the DON on 4/13/22 at 12:15 P.M. revealed she is unable to find any evidence of a care conference being completed since 07/14/21. Review of the facility Care Planning Conference policy dated 06/24/21 revealed on Admission, Quarterly, Annually, with a Significant Change and as needed, the interdisciplinary team will hold a care planning conference with the resident, family or representative in participation. The Care Conference will be used to identify the resident's potential or actual problems, needs, goals and discharge plans. A written invitation will be sent to the resident and/or family at least a week prior to care conference or as much in advance as possible. Efforts will be made to increase family/resident participation such as telephone conference calls, in room conferences etc. Ensure privacy and HIPAA regulations are adhered to. 3. Medical record review for Resident #37 revealed admission date 03/08/21. Diagnoses included epilepsy, ulcerative colitis with complications, depression, asthma, hyperlipidemia, schizoaffective disorder, gastro-esophageal reflux disease (GERD) without esophagitis, cognitive communication deficit, anxiety, and insomnia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Resident #37 required extensive assistance of one person for bed mobility. The resident required extensive assistance of two persons for transfers. Review of Resident Care Conferences Minutes revealed the resident had a Care Conference on 10/20/21 and on 03/14/22. Resident #37 did not have Care Conferences from 10/20/21 through 03/14/22. Interview on 04/12/22 at 10:17 A.M. Resident #37 stated she had not been included in quarterly Care Conference Meetings. Interview on 04/14/22 at 12:20 P.M. the Assistant Director of Nursing (ADON) verified the facility had not complete quarterly Care Conference Meetings for Resident #37. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 4 of 13 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 04/18/2022 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 Based on record review and staff interview, the facility failed to ensure residents were invited to participate in their care plan. This affected four (#14, #38, #37 and #41) residents out of five residents reviewed for participation in care planning. The facility census was 49. Findings include: Residents Affected - Some 1. Review of the Resident #14's chart revealed Resident #14 admitted to the facility on [DATE] with diagnoses including displaced fracture of base of neck of left femur, unspecified dementia without behavioral disturbance, hypertensive heart disease without heart failure, constipation, pain in left hip, hyperlipidemia, history of falling, muscle weakness, and retention of urine. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #14 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #14 was also independent with eating. Review of Resident #14's care conferences revealed Resident #14 had care conferences on 09/13/21 and 11/01/21. Resident #14 did not have any care conferences from 11/01/21 to 04/13/21. Interview with the Director of Nursing (DON) on 04/13/22 at 12:45 P.M. verified Resident #14 had not had any care conferences from 11/01/21 to 04/13/21. 2. Review of the medical record for Resident #18 revealed an admission date of 04/29/21 with diagnoses including type two diabetes mellitus, schizoaffective disorder, dementia with behavioral disturbance, anxiety disorder, and hypertensive heart disease without heart failure. Review of the Quarterly MDS dated [DATE] revealed this resident had moderate cognitive impairment. This resident was assessed to require one-person extensive assistance with transfers, toileting, and bathing, one-person limited assistance with dressing, and independent with eating. Review of the care conference records for Resident #18 revealed a 72-hour admission conference was completed on 04/30/21. Review of the care conference records for Resident #18 revealed a care conference was completed on 08/13/21. Interview on 04/13/22 at 3:31 P.M. with the DON revealed a care conference had not been completed since 08/13/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 5 of 13 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 04/18/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observation, resident interview, and record review the facility failed to ensure a resident with a pressure ulcer receives the necessary treatment and services to promote healing when a dressing change for Resident #33 was not completed daily as ordered. This affected one (Resident #33) of three residents reviewed for pressure ulcers. The facility census was 49. Residents Affected - Few Findings include: Record review of Resident #33 revealed an admission date of 02/17/22 with pertinent diagnoses of: cardiac arrest, hemoperitoneum, type two diabetes mellitus with diabetic polyneuropathy, post cod-19 condition, chronic obstructive pulmonary disease, dysphagia, hyperlipidemia, hypertensive heart disease, seizures, dysphagia following cerebral infarction, atrial fibrillation, atherosclerotic heart disease, cerebral infarction, thrombocytopenia, depression, peripheral vascular disease, obstructive sleep apnea, chronic viral hepatitis C, anxiety disorder, bipolar disorder, disorder of autonomic nervous system, and benign prostatic hyperplasia. Review of the 02/24/22 admission Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and requires extensive assistance for bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. The resident used a wheelchair to aid in mobility, was receiving nutrition through a feeding tube and was frequently incontinent of bowel and bladder. The resident was at risk for a pressure ulcer and had interventions in place to include pressure reduction devices for bed and chair and applications of ointments/medications. Review of a Physician Order dated 03/16/22 revealed an order for a low air loss mattress. Review of a skin and wound evaluation dated 03/30/22 revealed Resident #33 developed a Deep Tissue Injury (DTI) pressure to his right heel measuring 4.5 centimeters (cms) in length by 3.2 cms in width with a not applicable depth. Review of a Physician Order dated 03/30/22 revealed apply skin prep to DTI to Right heel every shift. Review of a Physician Order dated 04/04/22 revealed apply skin prep to deep tissue injury to right heel and cover with Adaptic dressing, abdominal dressing and Kerlix every evening shift. Review of a skin and wound evaluation dated 04/06/22 revealed Resident #33's right heel measured 6.3 centimeters (cms) in length by 2.3 cms in width with a not applicable depth. Interview with Resident #33 on 04/12/22 at 8:58 A.M. revealed he has a deep tissue injury to his right heel and they did not change the dressing to it last night. Observation with Registered Nurse (RN) #83 on 04/12/22 at 12:33 P.M. revealed Resident #33 had a low air loss mattress and his right foot dressing was soiled and dated 04/10/22. The dressing was initialed with the nurses initials who worked on 04/10/22. Observation with RN #83 on 04/12/22 at 12:47 P.M. revealed Resident #33 wound measured 6.5 cms length by 9.0 cms width and 0.1 or less depth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 6 of 13 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 04/18/2022 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a Progress Note Details for a wound note dated 04/13/22 revealed wound #6 right heel is a Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 6 cm length x 8 cm width x 0.1 cm depth, with an area of 48 sq cm and a volume of 4.8 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a moderate amount of yellow drainage noted which has a strong odor. The patient reports no wound pain due to the wound being insensate. The wound margin is attached to wound base. Wound bed has 51-75 %epithelialization, 76-100 % bright red, pink, firm granulation. The wound is deteriorating. The periwound skin exhibited: Moist, Maceration, Erythema. The temperature of the periwound skin is Warm. Periwound skin presents with signs of infection. Confirmation description and treatment plan is: signs and symptoms present, systemic antibiotics prescribed, topical antibiotics prescribed. Local pulse is Weak. General Notes: removed dead, macerated skin that was the blister roof exposing the entire wound surface. Peri-wound with redness, edema, increased yellow drainage, macerated, and measuring larger than last week - clinical suspicion high for infection - will start oral antibiotic. DTI is in evolution and likely to be staged next visit. Patient tolerated procedure very well with minimal bleeding and wound was redressed. Event ID: Facility ID: 365552 If continuation sheet Page 7 of 13 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 04/18/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #10 revealed an admission date of 04/25/21 with pertinent diagnoses of: cerebral infarction, cognitive communication, deficit, type two diabetes mellitus, vitamin D deficiency, major depressive disorder, hyperlipidemia, old myocardial infarction, benign prostatci hyperplasia, hypertensive heart disease, gastroesophagael reflux disease, muscle weakness, and anxiety disorder. Review of the Medical record on 04/12/22 revealed Resident #10 had pharmacy recommendations on 01/27/22, 11/16/21, 10/20/21, 09/22/21, and 08/13/21. Interview with the Director of Nursing (DON) on 04/14/22 at 09:30 A.M. verified the 09/22/21, and 08/13/21 pharmacy recommendations were not signed by the physician. Based on medical record review, review of facility policy, and interview the facility failed to implement pharmacy recommendations in a timely manner and provide documentation for completed monthly medication reviews. The affected five of five Residents (#11, #18, #19, #10, and #21) reviewed for unnecessary medications. The facility census was 49. Findings include: 1. Medical record review for Resident #11 revealed admission date 07/20/17. Diagnoses included muscle weakness, need for personal assistance, dysphagia, oral phase, peripheral vascular disease, osteoporosis, anxiety, gastro-esophageal reflux disease (GERD), constipation, and cognitive communication deficit. Review of the Consultant Report Laurels of Blanchester Omnicare of Cincinnati dated 02/20/22 revealed recommendation to reevaluate the need for both agents, azelastine nasal spray (NS) and Flonase NS. The facility physician signed the accepted recommendations with the following modifications: discontinue Flonase, on 03/28/22. Review of the Medication Administration Record for March 2022 revealed Flonase Suspension 50 microgram/actuation (mcg/act) one spray each nostril one time a day for allergy was discontinued 03/28/22. This finding was verified by the Director of Nursing (DON) on 04/13/22 at 12:15 P.M. 5. Review of the Resident #21's chart revealed Resident #21 admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizoaffective disorder, other abnormalities of gait and mobility, type two diabetes mellitus with hypoglycemia without coma, congestive heart failure, atrial flutter, asthma, anxiety disorder, muscle weakness, hyperlipidemia, depression, low back pain, anemia, and history of falling. Review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #21 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #21 was also independent with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 8 of 13 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 04/18/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of Resident #21's pharmacy recommendation dated 02/20/22 revealed Resident #21 received a leukotriene receptor antagonist, Montelukast Sodium and had a diagnosed psychiatric condition including bipolar disorder and depression. The pharmacy recommendation stated to please consider discontinuing montelukast sodium at that time. Further review of the pharmacy recommendation revealed Resident #21's physician accepted the recommendation on 03/28/22. Residents Affected - Some Interview with the Administrator on 04/12/22 at 3:54 P.M. verified Resident #21's pharmacy recommendation was made on 02/20/22 and was not addressed until 03/28/22. Review of a facility Timeliness of Medication Regimen Review (MRR) Reports policy dated 09/30/21 revealed The pharmacist will review and report any medication irregularities at least once a month. The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within three to five days of completion via secure e-mail or hard copy. The attending physician is expected to review the guest's/resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt. 2. Review of the medical record for Resident #18 revealed an admission date of 04/29/21 with diagnoses including type two diabetes mellitus, schizoaffective disorder, dementia with behavioral disturbance, anxiety disorder, and hypertensive heart disease without heart failure. Review of the Quarterly MDS dated [DATE] revealed this resident had moderate cognitive impairment. This resident was assessed to require one-person extensive assistance with transfers, toileting, and bathing, one-person limited assistance with dressing, and independent with eating. Review of Resident #18's pharmacy recommendation dated 02/17/22 revealed Resident #18 received Lactobacillus capsule, give one capsule by mouth one time a day for supplement. Review of the pharmacy review revealed a recommendation to discontinue acidophilus. Further review of the pharmacy recommendation revealed the physician addressed Resident #18's pharmacy recommendation on 03/28/22 and discontinued Lactobacillus. Review of Resident #18's physician order dated 10/30/21 revealed Lactobacillus capsule, give one capsule by mouth one time a day for supplement. Review of the medication administration record (MAR) dated March 2022 revealed Resident #18 received Lactobacillus until discontinuation on 03/28/22. Interview on 04/13/22 at 3:02 P.M. with the Director of Nursing (DON) verified Resident #18's pharmacy recommendation was made on 02/17/22 and was addressed by the physician on 03/28/22. 3. Review of Resident # 19's medical record revealed an admission date of 01/21/22. Diagnoses included but are not limited to the following: left ventricular heart failure, hyperlipidemia, dementia, anxiety disorder, type two diabetes mellitus, restless leg syndrome, muscle weakness, major depressive disorder, chronic kidney disease, abnormalities of gait and mobility. Review of Resident # 19's Medication Regimen Review dated 02/17/22 revealed Resident # 19 was receiving Ativan one milligram daily as needed. A recommendation was made to consider discontinuation due to as needed non-antipsychotic psychotropic medications not to exceed 14 days without physician providing diagnosis, rationale for extended time period and duration of as needed order. Medication Regimen Review revealed documented physician response of on twice daily routine on 03/28/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 9 of 13 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 04/18/2022 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, facility policy, interview, and review of the facility procedure guide, the facility failed to monitor blood glucose levels for a resident with insulin administration orders. This affected one (Resident #149) of three Residents reviewed for insulin administration. The facility census was 49. Residents Affected - Few Findings include: Medical Record review for Resident #149 revealed admission date 03/28/22. Diagnoses included Diabetes Mellitus Type 2 (DM2), fracture of third metatarsal right foot, displaced fracture of second metatarsal bone, right foot, chronic obstructive pulmonary disease (COPD), chronic kidney disease, schizoaffective disorder, and obstructive sleep apnea (OSA). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two plus persons for bed mobility and transfers. The resident received insulin injections on seven of past seven days. Review of the Plan of Care dated 03/29/22 revealed Resident #149 is at risk for fluctuation in blood sugar levels related to: DM, Psychotropic drug use, requires daily insulin, requires sliding scale insulin. Administer medication/injectable medication as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician. Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Observe for sign/symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Report abnormal findings to the physician. Observe for signs/symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Report abnormal findings to the physician. Obtain labs and diagnostics as ordered and report findings to the physician. Review of physician orders for March 2022 revealed Novolog Mix 70/30 Flex Pen Suspension Pen-injector (70-30) 100 units/milliliter (unit/ml) (Insulin Aspart Prot&Aspart). Inject 50 unit subcutaneously two times a day for DM2. Ozempic (1 mg/dose) Solution Pen-injector 4 mg/3 ml (Semaglutide (1 mg/dose)). Inject 1 mg subcutaneously two times a day for DM2. There were no orders for glucose monitoring. Review of vital signs on 03/28/22 at 6:31 P.M. revealed blood glucose 279 milligrams per deciliter (mg/dL). Interview on 04/14/22 at 10:38 A.M. the facility physician stated she had verified with the resident's family the resident had been on the ordered insulin dose for many years, and she was stable. She stated the family had requested the dose not be adjusted. She stated the facility liked the resident to be in the facility for two to three weeks and then would check labs to monitor for needed adjustments. She stated the resident entered the facility from the hospital. Interview on 04/14/22 at 11:17 A.M. Omnicare Pharmacist #95 stated insulin administration typically included blood sugar monitoring two to four times a day. She stated in a long-term care setting, the expectation would include blood glucose monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 10 of 13 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 04/18/2022 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 04/14/22 at 11:27 A.M. Resident #149 stated she checked her blood sugar four times a day at home. She stated she received 50 units of insulin two times a day. She stated her doctor instructed her to check her blood sugar four times a day. She stated her results should be between 100 and 200. Review of facility procedure guide titled Lippincott procedures-Blood glucose monitoring, long-term care, undated, revealed a portable blood glucose monitor provides quantitative measurements that are comparable in accuracy to other laboratory tests that measure blood glucose level. Most monitors store successive test results electronically to help determine glucose patterns. For a resident who's receiving nutrition, glucose monitoring should be performed before meals. Event ID: Facility ID: 365552 If continuation sheet Page 11 of 13 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 04/18/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and staff interview the facility failed to ensure that its medication error rate was less than five percent when they failed to administer senna (laxative medication) for Resident #26, and ferrous sulfate (iron supplement) and gabapentin (anticonvulsant and nerve pain medication) for Resident #99. This affected two Residents (#26 and #99) of five observed for medication administration. There was 29 opportunities with three errors for a medication error rate of 10.34%. The facility census was 49. Residents Affected - Few Findings include: 1. Record Review of Resident #26 revealed an admission date of 02/04/22 with pertinent diagnoses of: lumbar spinal cord injury, constipation, secondary Parkinsonism, and low back pain. Review of the 02/08/22 Physician Order revealed an order for Senna (laxative medication) Tablet 8.6 milligrams (mgs) give one tablet by mouth two times a day for aid bowel movement. Observation of a medication administration pass on 04/13/22 at 8:48 A.M. revealed Licensed Practical Nurse (LPN) #4 administered morning medication for Resident #26 including, miralax, tramadol, and tizanidine. LPN #4 did not administer senna 8.6 mgs. LPN #4 was asked if she had given all the morning medications and she responded this was all Resident #26 medication and she had not given any medications earlier. Interview with LPN #4 on 04/13/22 at 9:55 A.M. verified she did not administer Resident #26 senna 8.6 mgs with the morning medication pass. 2. Record Review of Resident #99 revealed an admission date of 04/12/22 with pertinent diagnoses of: low back pain, spinal stenosis with neurogenic claudication, and chronic kidney disease. Review of the 04/12/22 Physician Order revealed an order for Gabapentin oral capsule 400 mgs give 800 mgs by mouth three times a day for pain. Review of the 04/13/22 Physician Order revealed an order for ferrous sulfate oral tablet 325 mgs (65 mgs iron) give 325 mg by mouth one time a day for anemia. Observation of a medication administration pass on 04/13/22 at 8:55 A.M. revealed Licensed Practical Nurse (LPN) #4 administered morning medication for Resident #99 including lasix, lisinopril, metoprolol, and prednisone. LPN #4 did not administer ferrous sulfate 325 mgs or gabapentin 400 mgs two tabs. LPN #4 was asked if she had given all the morning medications and she responded this was all Resident #26 medication and she had not given any medications earlier. Interview with LPN #4 on 04/13/22 at 9:58 A.M. verified she did not administer Resident #99 ferrous sulfate 325 mgs or gabapentin 400 mgs two tabs as ordered with the morning medication pass. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 12 of 13 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 04/18/2022 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a resident's call light was functioning. This affected one (Resident #41) out of 24 residents reviewed for call light functioning. The census was 49. Residents Affected - Few Findings include: Review of the Resident #41's chart revealed Resident #41 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, neuromuscular dysfunction of bladder, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, hypertensive heart disease without heart failure, hyperlipidemia, muscle weakness, anxiety, and depression. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #41 required extensive assistance with bed mobility, toileting, personal hygiene, and dressing. Resident #41 also required total dependence with transfers and supervision with eating on the MDS. Review of Resident #41's fall care plan revised on 04/26/21 revealed Resident #41 was at risk for falls. Interventions included to keep the resident's call light within reach and encourage resident to use his call light for assistance as needed. Observation of Resident #41's call light on 04/11/22 at 8:36 A.M. revealed Resident #41's call light was not functioning. Observation of Resident #41's call light on 04/14/22 at 9:06 A.M. revealed Resident #41's call light was not functioning. Interview on 04/14/22 at 9:06 A.M. with State Tested Nurse Aide (STNA) #72 verified Resident #41's call light was not functioning. Interview with Registered Nurse (RN) #83 on 04/14/22 at 9:22 A.M. verified Resident #41 was able to use his call light to request for assistance. Review of the facility's routine resident care policy dated 06/16/21 revealed call lights should be answered timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365552 If continuation sheet Page 13 of 13