Inspection·November 26, 2019

F 0578 computer was not working or if the nurse was not on the unit at the time of an emergency the staff should look at the resident's [NAME] to determine the resident's code status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 2 of 17 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 11/26/2019 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the attending physician of elevated resident blood sugars. This affected one (#27) of six residents reviewed for medications. The census was 75. Findings include: Review of record for Resident #27 revealed as admission date of 05/01/17 with a diagnosis of diabetes. Review of Minimum Data Set (MDS) dated [DATE] for Resident #27 revealed resident had mild cognitive impairment and required supervision with activities of daily living. Review of November 2019 physician orders for Resident #27 revealed an order for insulin be administered per a sliding scale and that if blood sugar was above 450 to administer 12 units of insulin and then to recheck the blood sugar in one hour and notify the physician. Review of the Medication Administration Record (MAR) for November 2019 for Resident #27 revealed the resident's blood sugar (BS) was over 450 on the following dates/times: 11/01/19 at 3:30 P.M.- BS was 492, 11/11/19 at 630 A.M.-BS was 552, 11/14/19 at 6:30 A.M.-BS was 482, 11/16/19 at 6:30 A.M.-BS was 537, 11/20/19 at 6:30 A.M. BS was 492. Review of the medical record for Resident #27 including nurse progress notes and fax notification records to the physician for the month of November 2019 revealed no evidence of physician notification per the physician's order for the elevated blood sugars on the following dates: 11/01/19 at 3:30 P.M.-BS was 492, 11/11/19 at 630 A.M.-BS was 552, 11/14/19 at 6:30 A.M.-BS was 482, 11/16/19 at 6:30 A.M.-BS was 537, 11/20/19 at 6:30 A.M.-BS was 492. Interview with Director of Nursing (DON) on 11/26/19 at 7:45 A.M. confirmed that the facility had no evidence that the attending physician was notified per the physician's order of the following blood sugars for Resident #27 that were above 450: 11/01/19 at 3:30 P.M. BS was 492, 11/11/19 at 630 A.M. BS was 552, 11/14/19 at 6:30 A.M. BS was 482, 11/16/19 at 6:30 A.M. was 537, 11/20/19 at 6:30 A.M. was 492. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 3 of 17 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 11/26/2019 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, and review of facility policy, the facility failed to provide a comfortable and homelike dining experience for residents residing on the female secured unit. This affected two (#58 and #71) of five residents observed for dining on the unit. The census was 75. Findings include: Review of record for Resident #58 revealed resident was admitted on [DATE] with a diagnosis of dementia without behavioral disturbance. Review of Minimum Data Set (MDS) for Resident #58 dated 10/03/19 revealed resident was cognitively impaired and required supervision with eating. Review of record for Resident #71 revealed resident was admitted on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance. Review of MDS for Resident #71 dated 11/07/19 revealed resident was cognitively impaired and required limited assistance of one staff with eating. Review of care plans for Resident #58 and Resident #71 revealed neither resident was care planned for any alternate dining preferences such as choosing to eat off an end table versus eating at the dining room table. Observation of the lunch meal at 11: 55 A.M. confirmed that Residents #5 and #7 were eating lunch at a standard height dining room table in the dining room, and Residents #58 and #71 were served their lunch which consisted of beef pot roast, baked potato, carrots, roll, and apple pie, on an end table which was situated between the chairs where the two residents were sitting. Resident #27 was sitting on the table with Residents #5 and #7 but was not eating. The end table was approximately two feet in height and residents fed themselves from their meal trays which were placed laterally to the residents as opposed to the other residents (#5 and #7) who fed themselves from a standard dining room table with their meals placed directly in front of them. There was a second dining room table in the dining room but it was pushed against the wall and had puzzles and games stored on top of it. Interview on 11/24/19 at 11:55 A.M. with Residents #58 and #71 confirmed that the residents would have preferred to eat at the dining room table but they expressed concern that there was no room for them in the dining room, and they didn't want to complain. Interview on 11/24/19 at 12:00 P.M. with Licensed Practical Nurse (LPN) #19 and State Tested Nursing Assistant (STNA) #59 confirmed that they had served Residents #58 and #71 their lunch on an end table versus a dining room table and they did not have a rationale as to why these residents ate their meal off the end table. LPN #19 and STNA #59 further confirmed they were not sure what the preference was for Residents #58 and #71 regarding their meal service. LPN #19 confirmed that Resident #27 had already eaten lunch off the unit prior to the meal service on 11/24/19 and also that there was no seating chart or assigned seating for the dining room in the secured unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 4 of 17 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 11/26/2019 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 0584 Review of facility policy titled Secured Unit Dining Experience dated 07/01/18 revealed residents should be seated at the same place in the dining room to provide a sense of routine and continuity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 5 of 17 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 11/26/2019 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility self-reported incidents (SRI's), resident and staff interview, and review of facility policy, the facility failed to report an allegation of possible resident to resident physical abuse to the state agency. This affected one (#5) of three residents reviewed for abuse concerns. The census was 75. Findings include: Review of record revealed Resident #5 was admitted on [DATE] with a diagnosis of Alzheimer's disease. Review of Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed resident was cognitively intact and required limited assistance with activities of daily living. Review of record for Resident #73 revealed resident had a diagnosis of dementia with behavioral disturbance and was discharged from the facility on 10/08/19. Review of nurse progress note dated 10/02/19 for Resident #73 revealed the resident swatted Resident #5 on her bottom and that Resident #5 was very upset and stated the other resident's action had startled her. Review of nurse progress note dated 10/03/19 for Resident #5 revealed the Director of Nursing (DON) interviewed Resident #5 regarding the incident which occurred on 10/02/19 involving Resident #73, and that Resident #5 denied any distress or injury and indicated that the other resident's actions startled her. Review of the facility SRI's for the month of October 2019 revealed no SRI was initiated related to the incident involving Resident #5 and Resident #73. Interview on 11/24/19 with Resident #5 confirmed that Resident #73 had come up behind her sometime in October and swatted her on the behind. Resident #5 confirmed that she had not been injured but that it had startled her and that she did not like it and was glad that Resident #73 was no longer at the facility. Interview on 11/25/19 at 9:14 A.M. with the Director of Nursing (DON) confirmed that the facility staff had reported the incident involving Resident #5 and #73 on 10/02/19 to her immediately, and that she had interviewed the parties involved and that her investigation had determined that abuse had not occurred. DON confirmed that the facility had not initiated an SRI regarding the incident. Interview on 11/25/19 at 1:00 P.M. with the Administrator confirmed that facility staff had reported the incident involving Resident #5 and #73 on 10/02/19 to her immediately, and that she had also interviewed the parties involved and that she felt abuse had not occurred. Administrator also confirmed that an SRI had not been initiated regarding the incident and that allegations of potential abuse included resident to resident abuse should be reported to the state agency. Review of policy titled Abuse Prohibition, Investigation, and Reporting dated 07/19 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 6 of 17 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 11/26/2019 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 0609 facility will report allegations of abuse, including resident to resident abuse, to the state agency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 7 of 17 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 11/26/2019 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 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, resident and staff interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to accurately assess resident dental status. This affected one (#66) of three residents reviewed for dental concerns. The census was 75. Residents Affected - Few Findings include: Review of record for Resident #66 revealed an admission date of 04/11/14 with a diagnosis of schizophrenia. Review of the quarterly Minimum Data Set (MDS) for Resident #66 dated 10/01/19 revealed the resident was cognitively intact and required extensive assistance with activities of daily living. Review of the comprehensive MDS for Resident #66 dated 10/30/19 section V, care area assessment worksheet for dental care revealed the resident had no natural teeth and was at risk for chewing issues and mouth pain related to denture use, that resident needs assistance with denture care, and that a care plan would be developed to avoid complications and minimize risks related to denture use. Review of care plan for Resident #66 dated 11/12/19 revealed resident had a self care performance deficit related to fluctuations with cognition, mood, and behaviors. Interventions included the following: encourage resident to brush dentures, provide assistance as needed with upper and lower dentures, encourage denture use. Review of the [NAME] for Resident #66 revealed resident had upper and lower dentures but that she refused to wear them. Review of the dental visit note for Resident #66 dated 05/13/19 revealed resident had no natural teeth, that she had worn dentures at one time, but she was no longer a candidate for dentures due insufficient bone structure inside resident's mouth to support a denture. Interview on 11/24/19 at 3:08 P.M. with Resident #66 confirmed she had not had dentures for about two years and that she wanted to have dentures. Interview on 11/25/19 at 5:05 P.M. with State Tested Nursing Assistant (STNA) #43 confirmed Resident #66 does not have dentures and has not had dentures for as long as she has been working with resident which is approximately one year. Interview on 11/26/19 at 9:00 A.M. with the Director of Nursing (DON) confirmed that Resident #66 was edentulous, that she has not had dentures for at least a year, that resident was seen by the facility dentist on 05/13/19 who determined resident was not appropriate for denture use. DON further confirmed that Resident #66's MDS dated [DATE] did not accurately reflect the resident's dental status. Review of the Resident Assessment Instrument (RAI) Manual updated October 2019 page 4-35 revealed information gleaned from the assessment should be used to identify the oral/dental issues and/or conditions and to identify any related possible causes and/or contributing risk factors in order to develop an individualized care plan for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 8 of 17 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 11/26/2019 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 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 resident and staff interview, the facility failed to update resident care plans regarding dental status. This affected one (#66) of three residents reviewed for dental concerns. The census was 75. Findings include: Review of record for Resident #66 revealed an admission date of 04/11/14 with a diagnosis of schizophrenia. Review of the quarterly Minimum Data Set (MDS) for Resident #66 dated 10/01/19 revealed the resident was cognitively intact and required extensive assistance with activities of daily living. Review of the comprehensive MDS for Resident #66 dated 10/30/19 section V, care area assessment worksheet for dental care revealed the resident had no natural teeth and was at risk for chewing issues and mouth pain related to denture use, that resident needs assistance with denture care, and that a care plan would be developed to avoid complications and minimize risks related to denture use. Review of care plan for Resident #66 dated 11/12/19 revealed resident had a self care performance deficit related to fluctuations with cognition, mood, and behaviors. Interventions included the following: encourage resident to brush dentures, provide assistance as needed with upper and lower dentures, encourage denture use. Review of the [NAME] for Resident #66 revealed resident had upper and lower dentures but that she refused to wear them. Review of the dental visit note for Resident #66 dated 05/13/19 revealed resident had no natural teeth, that she had worn dentures at one time, but she was no longer a candidate for dentures due insufficient bone structure inside resident's mouth to support a denture. Interview on 11/24/19 at 3:08 P.M. with Resident #66 confirmed she had not had dentures for about two years and that she wanted to have dentures. Interview on 11/25/19 at 5:05 P.M. with State Tested Nursing Assistant (STNA) #43 confirmed Resident #66 does not have dentures and has not had dentures for as long as she has been working with resident which is approximately one year. Interview on 11/26/19 at 9:00 A.M. with the Director of Nursing (DON) confirmed that Resident #66 was edentulous, that she has not had dentures for at least a year, that resident was seen by the facility dentist on 05/13/19 who determined resident was not appropriate for denture use. DON further confirmed that Resident #66's care plan did not accurately reflect resident's dental status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 9 of 17 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 11/26/2019 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff and family interviews, the facility failed to ensure staff implemented a wheelchair cushion used as a positioning device and a finger splint ordered to treat a fractured finger. This affected one (#223) of one residents reviewed for position/mobility during the annual survey. The facility census was 75. Residents Affected - Few Findings include: Review of the medical record revealed Resident #223 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia with behavioral disturbance, wandering, rheumatoid arthritis, major depressive disorder, anxiety disorder, and atrophy. Review of the five-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #223 severely cognitively impaired with delirium inattention and disorganized thinking behaviors noted continuously. Review of Section G- Functional Status revealed the resident required extensive two-person assistance with bed mobility, toileting, personal hygiene, supervision with two-person assistance with transfer, limited two-person assistance with dressing, and supervision with setup assistance with eating. Review of Physician Order dated 11/20/19 revealed Resident #223 was ordered to have a pressure reduction cushion to his wheelchair every shift. Further review of the Physician Orders revealed the resident was also ordered, on 11/19/19, a finger splint to the left fourth digit, leave the splint in place and secured with ace wrap. Splint may be removed for showers/hygiene, and once per shift to assure circulation and skin integrity. Interview conducted on 11/24/19 at 3:27 P.M. with Resident #223 family, revealed the resident had recently broken his finger and wears a splint and also required the use of a wheelchair for mobility. The family voiced concerns regarding how low the resident sat to the ground in his wheelchair, he did not have a cushion in place. Observations conducted on 11/24/19 at 3:27 P.M. and 11/25/19 at 2:30 P.M. Resident was observed in wheelchair with no cushion in place. Observation conducted on 11/24/19 at 3:27 P.M. Resident #223 was observed with his finger splint in place. Further observations noted on 11/25/19 at 2:30 P.M. and 5:23 P.M. the resident was observed without in finger splint in place, finger splint was observed in the resident's room, sitting on his dresser. Interviews conducted on 11/25/19 at 2:30 P.M. and 5:23 P.M. with State Tested Nursing Assistant's (STNA) (#48, #53, and #80). STNA #80 stated she was the aide caring for the resident today. STNA's (#48, #53, and #80) all stated the resident did not have a cushion for his wheelchair, and he did not wear a hand splint, that they were aware of. STNA #48 verified Resident #223's finger splint was noted on his dresser, however stated she had never observed the resident wearing it and she works with him all the time. Interview conducted on 11/25/19 at 2:36 P.M. and 3:10 P.M. with Physical Therapy (PT) #73 and Therapy Manager (TM) #71 verified they resident had no wheelchair cushion. PT #73 stated they put him in a lower wheelchair because he was falling or putting himself on the ground. TM #71 stated they put the wheelchair cushion back on the resident's wheelchair, she was not sure what happened to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 10 of 17 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 11/26/2019 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 0684 cushion, but usually residents always have one on their wheelchair. Level of Harm - Minimal harm or potential for actual harm Interview conducted on 11/25/19 at 6:31 P.M. with Licensed Practical Nurse (LPN) #22, verified she was the nurse caring for Resident #223. LPN #22 stated she was not aware of the resident wearing a splint. LPN #22 verified physician orders for the resident to wear the splint to his left hand, and further verified the orders for the resident to also have a cushion in place for his wheelchair. LPN #22 verified the resident had not had the ordered finger splint in place all day shift, and the facility provided a wheelchair cushion for the resident after it was brought to staff attention by the surveyor. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 11 of 17 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 11/26/2019 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interview, and review of the facility policy, the facility failed to ensure fall prevention measures were in place in accordance with the resident's care plan. This affected one (#7) of three residents reviewed for accidents. The census was 75. Findings include: Review of record revealed Resident #7 was admitted [DATE] with diagnoses which included low back pain and other chronic pain. Review of Minimum Data Set (MDS) for Resident #7 dated 11/17/19 revealed resident had cognitive impairment and required limited assistance with activities of daily living. Review of fall risk assessment for Resident #7 dated 09/18/19 revealed resident was at risk for falls. Review of care plan for Resident #7 dated 09/18/19 revealed resident was at risk for falls or fall related injury related to impaired mobility, muscle weakness, and impaired cognition. Interventions included the following: assess the risk level for falls on admission and as needed, encourage resident to wear non-skid foot wear when out of bed, assist resident as needed, fall mat beside bed when in bed. Review of [NAME] for Resident #7 revealed resident was to have have a fall mat placed beside her bed when resident was in bed. Observation of Resident #7 on 11/25/19 at 2:09 P.M. revealed resident was resting in bed and that there was no fall mat beside the resident's bed. Interview on 11/25/19 at 2:09 P.M. with Resident #7 confirmed resident was not aware that she was supposed to have a fall mat. Interview on 11/25/19 at 2:10 P.M. with State Tested Nursing Assistant (STNA) #43 confirmed that Resident #7 was resting in bed, that there was no fall mat beside the resident's bed and that she did not think resident was supposed to have a fall mat. Interview on 11/25/19 at 2:12 P.M. with Licensed Practical Nurse (LPN) #22 confirmed Resident #7 was resting in bed, that there was no fall mat beside the resident's bed and that she did not know if resident was supposed to have a fall mat. Interview on 11/25/19 at 3:15 P.M. with the Director of Nursing (DON) confirmed that the intervention of a fall mat to the beside of Resident #7 when resident was in bed was added to the resident's care plan as a fall prevention measure on 07/15/19, and that resident was supposed to have a fall mat in place to the bedside when resident was in bed. Review of facility policy titled Fall Management dated 10/2019 reveled the facility would develop and implement interventions to prevent and minimize resident falls and risk of injury related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 12 of 17 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 11/26/2019 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 0689 falls. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 13 of 17 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 11/26/2019 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 resident and staff interview, and review of facility policy the facility failed to assess and manage resident pain. This affected one (#7) of 18 residents sampled. The census was 75. Residents Affected - Few Findings include: Review of record revealed Resident #7 was admitted [DATE] with diagnoses which included low back pain and other chronic pain. Review of Minimum Data Set (MDS) for Resident #7 dated 11/17/19 revealed resident had cognitive impairment, required limited assistance with activities of daily living, and was coded as negative for receiving pain medications, negative as receiving non-pharmacological interventions for pain, and rated her pain during the assessment window as a seven on a scale of zero to 10 with 10 being the worst pain. Review of November 2019 physician orders for Resident #7 revealed no orders for pain medication. Review of care plan for Resident #7 dated 11/19/19 revealed resident was at risk for pain related to decreased mobility, diagnoses of chronic pain and generalized pain and discomfort. Interventions included the following: administer medications as ordered, observe for ineffectiveness and side effects, report abnormal finding to the physician, anticipate resident's need for pain relief as needed and respond immediately to any complaint of pain, encourage/provide non-pharmacological interventions to prevent/manage pain, evaluate characteristics of pain on a scale of zero to 10, observe for pain presence every shift as needed. Review of pain evaluation for Resident #7 dated 11/15/19 revealed resident reported she had experienced frequent pain over the last five days and the worst level of pain was rated by the resident as a level seven on a scale of zero to 10 with 10 being the worst pain. Review of pain evaluation for Resident #7 dated 11/25/19 revealed resident reported she had experienced frequent pain over the last five days and the worst level of pain was rated by the resident as a level six on a scale of zero to 10 with 10 being the worst pain. Review of nurse progress notes for Resident #7 dated 11/01/19 through 11/24/19 revealed notes did not contain documentation regarding assessment of resident pain and pain level and/or pain management interventions. Review of Medication Administration Record (MAR) for Resident #7 for November 2019 revealed it did not include an assessment of resident's pain level. Interview on 11/24/19 at 11:01 A.M. with Resident #7 confirmed she has chronic back pain, that she used to take medication for it but that she hasn't had any treatment for her pain in the past month. Interview on 11/25/19 at 5:25 P.M. with Resident #7 confirmed resident was having aching type pain to her lower back which she rated as eight on a scale of zero to 10, that no one had asked her about her pain today, and that she had not reported it to the nurse because she didn't want to complain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 14 of 17 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 11/26/2019 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 11/25/19 at 5:30 P.M. with Licensed Practical Nurse (LPN) #22 confirmed that Resident #7's record for November 2019 did not contain assessments of resident's pain and that resident had no medications or non-pharmacological pain interventions listed in her physician orders. Interview on 11/25/19 at 5:46 P.M. with the Director of Nursing (DON) that Resident #7's record for November 2019 was silent regarding assessment of resident's pain and that resident had no medications or non-pharmacological pain interventions listed in her physician orders. DON further confirmed that the facility would assess resident for pain immediately and notify Resident #7's attending physician of the results of the assessment. Event ID: Facility ID: 365558 If continuation sheet Page 15 of 17 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 11/26/2019 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 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 and staff interview, the facility failed to adequately monitor resident blood sugar per the physician's order related to insulin administration. This affected one (#27) of six residents reviewed for medications. The census was 75. Residents Affected - Few Findings include: Review of record for Resident #27 revealed as admission date of 05/01/17 with a diagnosis of diabetes. Review of Minimum Data Set (MDS) dated [DATE] for Resident #27 revealed resident had mild cognitive impairment and required supervision with activities of daily living. Review of November 2019 physician orders for Resident #27 revealed an order for insulin be administered per a sliding scale and that if blood sugar was above 450 to administer 12 units of insulin and then to recheck the blood sugar in one hour and notify the physician. Review of the Medication Administration Record (MAR) for November 2019 for Resident #27 revealed the resident's blood sugar (BS) was over 450 on the following dates/times: 11/01/19 at 3:30 P.M.- BS was 492; 11/11/19 at 630 A.M.-BS was 552; 11/14/19 at 6:30 A.M.-BS was 482; 11/16/19 at 6:30 A.M.-BS was 537 and 11/20/19 at 6:30 A.M.-BS was 492. Review of the medical record for Resident #27 including nurse progress notes and MAR for November 2019 revealed no follow-up rechecks in one hour after insulin administration for blood sugars over 450 for the following dates/times: 11/01/19 at 3:30 P.M.- BS was 492; 11/11/19 at 630 A.M.-BS was 552; 11/14/19 at 6:30 A.M.-BS was 482; 11/16/19 at 6:30 A.M.-BS was 537 and 11/20/19 at 6:30 A.M. BS was 492. Interview with Director of Nursing (DON) on 11/26/19 at 7:45 A.M. confirmed that the facility had no evidence that Resident #27's blood sugar was rechecked in one hour after insulin administration for blood sugars that were above 450: 11/01/19 at 3:30 P.M. BS was 492; 11/11/19 at 630 A.M. was 552; 11/14/19 at 6:30 A.M. was 482; 11/16/19 at 6:30 A.M. was 537 and 11/20/19 at 6:30 A.M. was 492. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 16 of 17 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 11/26/2019 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. Based on observation, staff interview, review of manufacturer's instructions and review of facility policy, the facility failed to properly store resident medications and discard expired medications. This had the potential to affect all 24 of the resident residing on the 100 Hall with the exception of Resident #26 whom the facility identified as having a contraindication to receiving a tuberculin testing solution injection, eleven facility identified residents residing on the 100 hall with orders for Melatonin, (Residents #21, #26, #31, #49, #53, #57, #62, #72, #173, #174, #175), seven facility-identified residents residing on the 100 hall who are diabetic (Residents #6, #11, #37, #52, #53, #72, #173), and two facility-identified residents residing on the 100 hall with orders for Phenergan (Residents #52, #175). The census was 75. Findings include: Observation of 100 Hall medication cart on 11/25/19 at 1:29 P.M. with Registered Nurse (RN) #24 revealed the cart contained a house stock bottle of Melatonin with a manufacturer's expiration date of 10/2019. Observation of the 100 Hall medication storage room on 11/25/19 at 1:50 P.M. refrigerator with RN #24 revealed the refrigerator contained a bottle of opened tuberculin testing solution which had not been dated upon opening. The refrigerator also revealed the following expired medications, none of which were assigned to a specific resident but were on hand as part of the facility's emergency supply: two Phenergan suppositories with an expiration date of 03/2019, two Phenergan suppositories with an expiration date of 03/201, an unopened vial of Novolin 70/30 insulin with an expiration date of 08/2019, an unopened vial of NPH insulin with an expiration date of 04/2019, three unopened vials of regular insulin with expiration dates of 10/2019 (two vials) and 10/2018 (one vial). Interview on 11/25/19 at 2:00 P.M. with RN #24 confirmed the tuberculin testing solution should be dated upon opening and that since it was not dated he was unsure when it should be discarded. Further interview with RN #24 confirmed that the expired Melatonin, Phenergan suppositories, and vials of insulin should have been discarded upon expiration. The facility confirmed this had the potential to affect all 24 of the resident residing on the 100 Hall with the exception of Resident #26 whom the facility identified as having a contraindication to receiving a tuberculin testing solution injection, eleven facility identified residents residing on the 100 hall with orders for Melatonin, (Residents #21, #26, #31, #49, #53, #57, #62, #72, #173, #174, #175), seven facility-identified residents residing on the 100 hall who are diabetic (Residents #6, #11, #37, #52, #53, #72, #173), and two facility-identified residents residing on the 100 hall with orders for Phenergan (Residents #52, #175 Review of manufacturer's recommendations for TB testing solution revealed that once a multi-dose vial was opened it should be discarded within 30 days. Review of policy titled Storage and Expirations of Medications dated 01/01/13 revealed that medications should not be retained longer than the expiration date marked on the container, and that once a medication or biological package is opened the facility should follow manufacturer's guidelines with respect to expiration dates for opened medications and that facility staff should record the date opened on the medication contained when the medication has a shortened expiration date once opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365558 If continuation sheet Page 17 of 17