Inspection·November 20, 2018

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, and review of facility policy, the facility failed to prevent verbal abuse of a resident. This affected one (Resident #35) of two residents reviewed for abuse. The facility census was 79. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including stage five chronic kidney disease, heart failure, atrial fibrillation, gastro-esophageal reflux disease(GERD), celiac disease, generalized anxiety disorder, cardiac pacemaker, irritable bowel syndrome, diverticulitis, and rheumatoid arthritis. Review of the Minimum Data Set(MDS) dated [DATE] revealed Resident #35 was cognitively intact. The resident required extensive two-person assistance with bed mobility, dressing and toileting, total two-person physical assistance with transfer, extensive one-person assistance with personal hygiene, and supervision setup with eating and locomotion. Further review of the functional assessment revealed the resident and bilateral lower extremity impairment and required a wheelchair for mobility. Interview conducted on 11/18/18 at 10:21 A.M. with Resident #35 revealed on 11/17/18, Lab Technician (LT) #105 came into her room to obtain blood for ordered labs. Resident #35 stated while she was trying to draw blood LT #105 started accusing her of not cooperating. Resident #35 stated LT #105 was yelling at her saying you don't drink enough fluids and I will send someone in here and they will poke you six times. Resident #35 stated she tried to inform LT #105 she was on fluid restriction due to her dialysis, but she wound not listen to her. Resident #35 stated the way LT #105 was yelling at her was verbal abuse. Resident #35 stated she told her not to talk to her that way she was her elder and she shouldn't speak to her elders that way. Resident #35 stated State Tested Nursing Assistant(STNA) #82 observed the incident and got the Licensed Practical Nurse(LPN) #22 who assessed her after the incident. Telephone interview conducted on 11/20/18 at 11:57 A.M. with STNA #82 revealed on 11/17/18 she was working in another room with another resident, when she heard Resident #35 screaming. STNA #82 stated she had never even heard Resident #35 raise her voice, so she ran down to her room to see what was wrong. STNA #82 stated upon getting to the door way she heard Resident #35 state, listen here little girl you need to mind your elders as to which LT #105 stated well you need to learn to listen. STNA #82 stated the way LT #105 was speaking to Resident #35 was definitely inappropriate and she should never talk to a resident that way. STNA #82 stated the two continued to argue back and forth and she immediately got the nurse. STNA #82 stated LT #105 left and she and LPN #22 assessed Resident #35 and noted no physical injuries. Interview conducted on 11/20/18 at 12:51 P.M., with the Administrator verified staff called about the abuse on Saturday right after it happened. The Administrator stated usually when lab staff come out to the facility they leave a sheet stating who they worked with and what they did. LT #105 did not leave anything when she. Administrator stated she got in contact with the facility representative for the lab company and explained the situation and requested that LT #105 no longer come to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 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 0600 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy Abuse Prohibition, Investigation, and Reporting dated 10/18 revealed the facility shall not allow verbal, mental, sexual, or physical abuse. Abuse in defined in the policy as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish by an individual. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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, staff and resident interviews, and review of facility policy, the facility failed to implement their abuse policy to ensure a resident is free from abuse. This affected one Resident #35 of two residents reviewed for abuse. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including stage five chronic kidney disease, heart failure, atrial fibrillation, gastro-esophageal reflux disease(GERD), celiac disease, generalized anxiety disorder, cardiac pacemaker, irritable bowel syndrome, diverticulitis, and rheumatoid arthritis. Review of the Minimum Data Set(MDS) dated [DATE] revealed Resident #35 was cognitively intact. The resident required extensive two-person assistance with bed mobility, dressing and toileting, total two-person physical assistance with transfer, extensive one-person assistance with personal hygiene, and supervision setup with eating and locomotion. Further review of the functional assessment revealed the resident and bilateral lower extremity impairment and required a wheelchair for mobility. Interview conducted on 11/18/18 at 10:21 A.M. with Resident #35 revealed on 11/17/18, Lab Technician (LT) #105 came into her room to obtain blood for ordered labs. Resident #35 stated while she was trying to draw blood LT #105 started accusing her of not cooperating. Resident #35 stated LT #105 was yelling at her saying you don't drink enough fluids and I will send someone in here and they will poke you six times. Resident #35 stated she tried to inform LT #105 she was on fluid restriction due to her dialysis, but she wound not listen to her. Resident #35 stated the way LT #105 was yelling at her was verbal abuse. Resident #35 stated she told her not to talk to her that way she was her elder and she shouldn't speak to her elders that way. Resident #35 stated State Tested Nursing Assistant(STNA) #82 observed the incident and got the Licensed Practical Nurse(LPN) #22 who assessed her after the incident. Telephone interview conducted on 11/20/18 at 11:57 A.M. with STNA #82 revealed on 11/17/18 she was working in another room with another resident, when she heard Resident #35 screaming. STNA #82 stated she had never even heard Resident #35 raise her voice, so she ran down to her room to see what was wrong. STNA #82 stated upon getting to the door way she heard Resident #35 state, listen here little girl you need to mind your elders as to which LT #105 stated well you need to learn to listen. STNA #82 stated the way LT #105 was speaking to Resident #35 was definitely inappropriate and she should never talk to a resident that way. STNA #82 stated the two continued to argue back and forth and she immediately got the nurse. STNA #82 stated LT #105 left and she and LPN #22 assessed Resident #35 and noted no physical injuries. Interview conducted on 11/20/18 at 12:51 P.M., with the Administrator verified staff called about the abuse on Saturday right after it happened. The Administrator stated usually when lab staff come out to the facility they leave a sheet stating who they worked with and what they did. LT #105 did not leave anything when she. Administrator stated she got in contact with the facility representative for the lab company and explained the situation and requested that LT #105 no longer come to the facility. Review of the facility policy Abuse Prohibition, Investigation, and Reporting dated 10/18 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 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 0607 Level of Harm - Minimal harm or potential for actual harm the facility shall not allow verbal, mental, sexual, or physical abuse. Abuse in defined in the policy as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish by an individual. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident had a physician's order for an enabling device. This affected one (Resident #26) of one residents reviewed for restraints. The facility census was 79. Findings include: Record review of Resident #26's chart revealed the resident was admitted to the facility on [DATE] with the following diagnoses; cerebrovascular disease, edema, epilepsy, intellectual disabilities, major depressive disorder and schizoaffective disorder. Review of Resident #26's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #26 also required total dependence with transfers and supervision with eating. Review of Resident #26's Physical Device Evaluation dated 10/25/18 revealed the resident's half tray table was used as an enabler for repositioning, increase independence, to provide a tactical barrier, to improve physical status and to improve emotional status. Review of Resident #26's care plan dated 11/19/18 revealed resident to was to have a a half tray table for positioning. Review of Resident #26's physician orders dated 11/19/18 did not reveal any orders for a half tray table. Observation of Resident #26 on 11/18/18 at 9:34 A.M. revealed the resident was sitting in her wheelchair with a hoyer pad underneath her. Resident #26 was observed to have a half tray table attached to her wheelchair. Further observation of Resident #26 revealed the resident was able to propel herself in her wheelchair with the half tray table attached to the wheelchair. Observation of Resident #26 on 11/18/18 at 11:19 A.M. revealed the resident was propelling herself in her wheelchair in the main dining room with her half tray table attached to the wheelchair. Interview with Assistant Director of Nursing (ADON) #21 on 11/20/18 at 12:00 P.M. verified Resident #26's half tray table order was not written until 11/20/18. ADON #21 confirmed Resident #26 had her half tray table for a while prior to the order being written. The ADON #21 was not able to provide an exact date of when Resident #26 started using the half tray table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to securely store medication in a locked medication cart in the 400 hall, the facility also failed to date an open medication vial, dispose of out dated medications in the 600 hall refrigerator, and properly secure medications in the 100 hall medication cart number two. This affected two (Hall cart #600 and Hall cart #100) of seven medication carts and one (Storage room [ROOM NUMBER]) of five storage rooms observed. The facility identified twelve residents (#6, #9, #16, #19, #20, #33, #36, #37, #42, #49, #55, and #60) residing in the 400 hall, twelve residents (#1, #5, #8, #22, #26, #39, #53, #61, #65, #72, #73, and #76) residing on the 600 hall, and nine Residents (#2, #3, #12, #31, #30, #41, #48, #63, and #69) receiving medication out of the 100 hall cart two who were cognitively impaired and independently mobile. The facility census was 79. Findings include: Observation and interview of medication storage conducted on [DATE] at 3:55 P.M. with Licensed Practical Nurse(LPN) #33 revealed the LPN unlocked and opened the medication storage refrigerator in the 600 hall. Medications including a vial Tuberculin(used to test for Tuberculosis) was observed to be opened and undated and a box of Biscolax(stool softeners) with the expiration date of 10/18 was observed. LPN #33 verified the expired Biscolax and undated Tuberculin stating the Tuberculin should have been dated when it was opened, and also stated the Biscolax should have been disposed of the end of last month. Medication observation and interview conducted on [DATE] at 7:58 A.M. LPN #41 was observed in the 400 hall cart gathering medication for a resident, shutting the drawers to the cart, collecting the medication cups then turning her back and walking away from the cart leaving it unlocked. LPN #41 verified the cart was left unattended and unlocked. Medication storage observation and interview conducted on [DATE] at 9:30 A.M. with Registered Nurse(RN) #77 revealed the RN unlocked 100 hall medication cart two for review. While reviewing the medication cart, four loose pills were noted in the bottom of three separate drawers of the medication cart. RN #77 verified medications should not be sitting in the bottom of the drawer and should in contained in packaging. Review of the facility policy Storage and Expiration of Medication dated [DATE] revealed medications should be securely stored in a locked cart that was inaccessible by residents and visitors. Once a medication was opened, staff should record the date opened on the medication container when the medication had a shortened expiration dated once opened, and the facility should also ensure medications are stored in the containers in which they were received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure food was served in a sanitary manner in the main dining room during a special event. This affected 43 residents (#1, #3, #4, #6, #8, #9, #10, #11, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #28, #29, #31, #37, #38, #39, #42, #43, #47, #48, #49, #53, #57, #58, #59, #61, #64, #67, #71, #72, #73, #74, #77 and #78) out of 79 residents residing in the facility. The facility census was 79. Findings include: Record review of Resident #25's chart revealed the resident was admitted to the facility on [DATE] with the following diagnoses; paranoid schizophrenia, history of traumatic brain injury, hypothyroidism, and hyperlipidemia. Review of Resident #25's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to have cognitive impairment and required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Observation of the Thanksgiving buffet meal in the main dining room on 11/18/18 at 11:19 A.M. revealed residents to be sitting at tables that were equipped with empty plates with decorative menus on the top of them. Residents were observed filling out the decorative menus on top of the plates. Further observation of the main dining room revealed staff to pick up plates and menus from residents and family members and place them in a stack near the serving station. Director of Food Service (DFS) #11, Housekeeping Supervisor (HKS) #42 and Marketing Director (MD) #45 were observed serving food items onto the plates that were previously sitting at resident tables. Observation of Activities Worker (AW) #16 on 11/18/18 at 11:30 A.M. revealed AW #16 to take plates off the tables where residents and family members were sitting and stack the plates on top of a current stack of plates from other resident's tables. AW #16 then put menu cards for residents on the bottom of a stack of existing resident menu cards. DFS #11 was observed taking plates from the top of the stack to serve the next menu on the top of the stack of menus. Interview with Activities Worker #16 on 11/18/18 at 11:30 A.M. verified the plates were not organized to ensure residents received their plates back and their plates did not come in contact with other residents or family member's plates. Observation of Business Office Manager (BOM) #29 on 11/18/18 at 11:45 A.M. revealed the staff member to approach the buffet serving station and report to DFS #11 that Resident #25 needed to be served next. DFS #11 was observed to place Resident #25 food onto a plate that was previously at another table. BOM #29 provided the plate to Resident #25. The facility identified Residents (#1, #3, #4, #6, #8, #9, #10, #11, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #28, #29, #31, #37, #38, #39, #42, #43, #47, #48, #49, #53, #57, #58, #59, #61, #64, #67, #71, #72, #73, #74, #77 and #78) that ate lunch in the main dining room on 11/18/18. Review of the facility's Buffet Style Meal Service policy dated April 2010 revealed, A new plate shall be used for every service from the buffet table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 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 365558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to implement their water control program used to monitor the risk, growth and spread of legionella. This had the potential to affect all residents. The facility census was 79. Residents Affected - Many Findings include: Review of the facility's undated Legionella Plan revealed the facility would monitor daily water temperatures, test the water quality weekly and clean off shower heads, sink facets, ice machines, dish machine, and coffee maker monthly. Review of the facility's monitoring of daily water temperatures, testing the water quality weekly and cleaning of shower heads, sink facets, ice machines, dish machine, and coffee maker monthly reveal no documentation of items being monitored, tested or cleaned. Interview with Director of Maintenance (DOM) #100 on 11/20/18 at 11:08 A.M. verified the facility had not completed any monitoring including monitoring daily water temperatures, testing the water quality weekly and cleaning of shower heads, sink facets, ice machines, dish machine, and coffee maker monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 9 of 9