Inspection·February 6, 2020

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, staff interview and facility policy review, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 85 residents residing in the facility. Residents Affected - Many Findings include: Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following employees: the Director of Nursing (DON) had a hire date of 02/14/19, Assistant Director of Nursing (ADON) #38 had a hire date of 09/20/19, Licensed Practical Nurse (LPN) Unit Manager #39 had a hire date of 02/21/19, Registered Nurse (RN) #42 had a hire date of 02/12/19, RN #45 had a hire date of 11/27/19, RN #47 had a hire date of 11/27/19, LPN #49 had a hire date of 12/05/19, LPN #51 had a hire date of 07/25/19, LPN #52 had a hire date of 11/27/19, LPN #53 had a hire date of 01/16/20, LPN #54 had a hire date of 08/15/19, LPN #55 had a hire date of 10/17/19, LPN #57 had a hire date of 01/09/20, LPN #58 had a hire date of 02/14/19, LPN #59 had a hire date of 02/28/19, LPN #60 had a hire date of 11/21/19, LPN #3 had a hire date of 01/17/20, LPN #5 had a hire date of 10/10/19, LPN #6 had a hire date of 01/09/20, LPN #8 had a hire date of 01/09/20, LPN #10 had a hire date of 01/16/20, Physical Therapy (PT) #105 had a hire date of 06/17/19, Speech Therapist (ST) #128 had a hire date of 09/23/19, Activities Aide (AA) #131 had a hire date of 10/10/19, Dietary Aide (DA) #132 had a hire date of 01/30/20, DA #133 had a hire date of 01/23/20, DA #134 had a hire date of 08/01/19, DA #136 had a hire date of 01/16/20, DA #137 had a hire date of 12/05/19, DA #138 had a hire date of 08/01/19, DA #140 had a hire date of 03/14/19, DA #141 had a hire date of 12/19/19, DA #143 had a hire date of 12/05/19, DA #145 had a hire date of 06/20/19, DA #146 had a hire date of 09/05/19, Dietary Manager (DM) #144 had a hire date of 08/15/19, Housekeeping (HSKP) #147 had a hire date of 12/19/19, HSKP #148 had a hire date of 09/20/19, HSKP #151 had a hire date of 01/23/20, HSKP #152 had a hire date of 10/31/19, HSKP #107 had hire of 04/11/19, Laundry Aide (LA) #110 had a hire date of 08/29/19, LA #111 had a hire date of 09/23/19, Medical Records (MR) #113 had a hire date of 01/03/19, Social Services (SS) #115 had a hire date of 10/03/19, Receptionist #117 had a hire date of 09/19/19 and Receptionist #120 had a hire date of 01/30/20. Interview with Human Resources (HR) #119 on 02/04/20 at 8:10 A.M. confirmed she was not aware the facility needed to check the State Nurse Aide Registry for all employees. HR #119 stated the facility did check the Nurse Aide Registry to see if the Certified Nurse Aides (CNAs) were in good standing but was not aware other employees were required to be checked against the Nurse Aide Registry. HR #119 verified the facility did not check the above mentioned employees on the Nurse Aide Registry to see if they were in good standing or had been reported to the Nurse Aide Registry. Review of the facility's policy titled Resident Abuse Prohibition, revised 10/01/18, revealed the facility would screen all prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating or misappropriating property/resources of residents by a court of law, or who is listed on the State Nurse Aide Registry. State Nurse Aide Registries for all states in which the applicant has worked are to be checked prior to employment. Any disqualifying findings eliminate the applicant from being considered for employment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365627 If continuation sheet Page 2 of 6 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 365627 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Huber Heights The 5440 Charlesgate Road Huber Heights, OH 45424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, event monitor education review, observation, staff and family interview, the facility failed to ensure interventions were put in place for a resident with a cardiac monitor. This affected one (Resident #185) of one resident reviewed for cardiac monitor. The census was 85. Residents Affected - Few Findings include: Medical record review for Resident #185 revealed an admission date of 01/20/20. Medical diagnoses included scoliosis and hypertension. Review of Event Monitor Education paperwork dated 01/19/20 revealed instructions to change the patch and charge the sensor for the cardiac monitor on 01/24/20, 01/29/20, and 02/03/20. Review of admission summary completed on 01/20/20 revealed Resident #185 was cognitively intact. She was an extensive assistance for bed mobility, transfers, toileting, and eating. Review of nursing comprehensive evaluation for skin and cardiovascular dated 01/20/20 revealed no mention of the cardiac monitor. Review of progress notes, physician orders and care plan from 01/20/20 through 02/03/20 for Resident #185 revealed no evidence of addressing the cardiac monitor device. Review of shower sheets dated on 01/28/20, 01/29/20 and 02/01/20 revealed no documentation of the cardiac monitor device. Interview with Resident #185's family member on 02/03/20 at 12:24 P.M. revealed the resident had a cardiac monitoring device on her chest. The device was used to check her for atrial fibrillation and was placed on the resident while she was at the hospital (prior to admission). The family stated they were concerned the facility wasn't monitoring the cardiac device for the resident. Observation of Resident #185 at the same time of the interview revealed the resident had an external device taped to the left side of her chest close to her heart. Interview with Unit Manger (UM) #39 on 02/06/20 at 9:00 A.M. revealed she didn't know Resident #185 had a cardiac monitoring device and would have to review the documentation for it. At 12:42 P.M., UM #39 still have not brought any information to the surveyor. Interview with Licensed Practical Nurse (LPN) #58 on 02/06/20 at 9:41 A.M. revealed she was the nurse who did the skin assessment for the resident on 01/20/20. LPN #58 said she looked at the residents skin but didn't see the cardiac device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365627 If continuation sheet Page 3 of 6 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 365627 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Huber Heights The 5440 Charlesgate Road Huber Heights, OH 45424 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, observation, and staff interview, the facility failed to have respiratory care orders in place for a resident with a tracheostomy (trach). This affected one (Resident #234) of five residents reviewed for respiratory care. The census was 85. Residents Affected - Few Findings include: Review of Resident #234's medical record revealed an admission date of 01/21/20. Diagnoses included malignant neoplasm of lung, acute respiratory failure with hypoxia, malignant neoplasm of left breast, and malignant neoplasm of bone. A comprehensive Minimum Data Set (MDS) had not yet been completed. Further review of Resident #234's medical record revealed she was admitted to the facility with a trach in place. Observation of Resident #234 on 02/03/20 at 11:15 A.M. revealed she had a trach in place, and was receiving humidified oxygen through that trach. Review of physician orders revealed no documentation of trach care or respiratory care orders related to a trach being entered before 02/04/20. Review of medication administration records (MARs) and treatment administration records (TARs) revealed no documentation of trach care or respiratory care orders related to a trach being entered before 02/04/20. Interview with the Director of Nursing (DON) on 02/04/20 at 3:48 P.M. confirmed trach care and respiratory care orders related to a trach were not entered entered until 02/04/20. The DON confirmed Resident #234 entered the facility with a trach and orders for care should have been entered on admission [DATE]. The DON also stated there was no documentation of trach care being provided to Resident #234 before 02/04/20, but she knew the care had been provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365627 If continuation sheet Page 4 of 6 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 365627 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Huber Heights The 5440 Charlesgate Road Huber Heights, OH 45424 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 Based on medical record review and staff interview, the facility failed to timely follow-up with physician recommendations. This affected one (Resident #80) of seven residents reviewed for unnecessary medications. The census was 85. Residents Affected - Few Findings include: Review of Resident #80's medical record revealed an admission date of 01/06/20. Diagnoses included radiculopathy of lumbar region, syncope and collapse, hypokalemia, major depressive disorder, anxiety disorder, hypertension, and obesity. Review of a pharmacy recommendation dated 01/08/20 revealed as needed (PRN) hydroxyzine (antihistamine) was recommended to be discontinued. Further review revealed it was signed by a physician on 01/08/20 who agreed with the recommendation to discontinue the PRN hydroxyzine. Review of physician orders revealed the PRN hydroxyzine was not discontinued until 01/31/20. Interview with the Director of Nursing (DON) on 02/04/20 at 2:09 P.M. confirmed a physician had signed a pharmacy recommendation to discontinue PRN hydroxyzine on 01/08/20 and it was not discontinued until 01/31/20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365627 If continuation sheet Page 5 of 6 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 365627 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Huber Heights The 5440 Charlesgate Road Huber Heights, OH 45424 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to have clear documentation in resident medical records. This affected one (Resident #38) of two residents reviewed for urinary tract infection (UTI). The census was 85. Findings include: Review of Resident #38's medical record revealed an admission dated of of 11/07/19. Diagnoses included anxiety disorder, major depressive disorder, hypertension, type 2 diabetes mellitus, UTI with extended spectrum beta lactamase (ESBL) resistance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had a multi-drug resistant organism (MDRO). Review of physician orders dated 01/05/20 revealed contact precautions for ESBL in urine. Review of treatment administration records (TARs) for January 2020 and February 2020 revealed contact precautions were signed off as being provided three times a day by nursing staff from 01/05/20 through 02/05/20. Review of nurse practitioner (NP) notes dated 02/04/20 revealed Resident #38 was recently treated at the emergency room (ER) on 01/27/20. Chronic colonization of ESBL was suspected and antibiotics would not be continued after current treatment ends. Observation of Resident #38's room on 02/04/20 at 8:34 A.M. revealed no isolation cart, personal protective equipment (PPE), or sign outside the room warning of isolation precautions. When the surveyor knocked on the door, staff members where inside the room and were not wearing any PPE, such as gowns. Follow-up observation at 02/05/20 at 8:03 A.M. revealed no isolation cart, PPE, or sign outside the room warning of isolation precautions. Interview with the Director of Nursing (DON) on 02/05/20 at 11:06 A.M. revealed Resident #38 was no longer on contact precautions following a recent ER visit. Follow-up interview with the DON on 02/06/20 at 7:48 A.M. and 8:50 A.M. revealed Resident #38's physician had removed isolation precaution on her return form the ER on [DATE] due to ESBL being colonized and chronic. The DON confirmed the documentation regarding Resident #38's isolation precautions were unclear and were documented as completed through 02/05/20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365627 If continuation sheet Page 6 of 6