Health inspection·August 23, 2021

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of a physician note dated 06/17/21, revealed Resident #21 had some general decline since her fall out of bed on 05/19/21, resulting in comminuted fractures of the proximal tibia and fibula being treating conservatively given age and advanced dementia with knee immobilizer. The physician noted the resident initially denied discomfort. The physician gently rotated the leg slightly and the resident complained of pain, more irritable and told the physician to stop. The physician noted an added bandage on the left heel, peeled back and the resident had a Stage II linear wound with no edema noted. Review of a nurses note dated 6/25/21 at 1:54 P.M., revealed Resident #21's immobilizer to the left leg was removed today to assess skin. A wound was noted to the left posterior lower leg; approximately 5.6 centimeters (cm) in length and 4.9 cm in width. Eschar was noted to the wound. There was a moderate amount of purulent drainage on the immobilizer. The physician ordered an antibiotic, Keflex 500 milligrams (mg) by mouth three times per day for ten days and to cleanse the area to the wound with normal saline, apply Santyl to eschar, cover with non-adherent dressing and wrap with Kerlix and paper tape. The physician ordered to discontinue the resident's leg immobilizer. Review of a physician order dated 06/25/21, revealed to administer Cephalexin 500 milligrams by mouth three times per day for the wound to left leg for ten days. Review of a skin and wound evaluation completed on 06/25/21 at 10:42 A.M., identified with a new facility acquired unstageable pressure ulcer to the left calf. The wound was unstageable due to slough and/or eschar. The wound measured 5.6 centimeters (cm) in length by 4.9 cm in width with no depth, no undermining and no tunneling. The wound bed was described as eschar with no percentage documented. There was redness/inflammation and increased pain with moderate purulent exudate. There was no documentation regarding odor or the periwound edges. The surrounding skin was noted as erythema. Pitting edema extending less than four centimeters around the wound. The new wound had suspected infection. The nurse practitioner was notified. Continued review of the wound note revealed the physician evaluated the wound and a treatment was in place. Review of a wound consult note dated 06/29/21, revealed the resident had history of fall in 05/2021, with immobilizer to the left leg. Nursing reported new wound to left posterior leg from immobilizer. The resident was noted on the antibiotic Keflex for a leg wound infection. The unstageable wound to the left posterior leg measured 5.2 cm in length by 5.1 in width by 0.4 cm in depth. The wound had moderate serous exudate with 100% slough/eschar. Debridement was completed to remove slough and eschar increasing depth to 0.5 cm. The wound practitioner ordered to cleanse with normal saline, pat dry, apply Santyl to wound bed, cover with 0.125% Dakins moist gauze, cover with abdominal pad (ABD) and gauze wrap, change daily and as needed. Review of the Treatment Administration Record (TAR) revealed the treatment to the left lower leg was not completed on 07/03/21, 07/14/21 and 07/18/21. Review of the wound nurse practitioner progress notes dated 07/09/21, revealed the wound to the posterior lower left extremity (LLE) measured 5.6 cm in length by 4.4 cm in width x 0.7 cm in depth. The wound was described as improving and had moderate serous exudate. The wound was 90% slough and eschar and 10% granulation tissue. Post debridement, the wound depth increased to 0.7 cm. Previous treatment orders were continued. Review of the wound nurse practitioner progress notes dated 07/20/21, revealed the unstageable wound to the posterior LLE measured 5.68 in length by 5.44 cm in width by 3.2 cm in depth. T he area was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 2 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 30% slough/eschar and 50% granulation tissue with moderate serosanguinous drainage and 20% tendon noted with 30% adipose and eschar mixture. No new treatment orders were initiated. Level of Harm - Actual harm Residents Affected - Few Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had impaired cognition. The resident required the extensive assistance of two staff for bed mobility, toileting, transfers and personal hygiene. The resident was at risk for developing pressure ulcers. The resident was noted with three unstageable pressure ulcers. Review of a physician order dated 07/24/21, revealed to offload bilateral lower extremities by placing pillow under knees and calves, then noodle under ankles. Reposition frequently throughout shift on all three shifts. Review of the wound nurse practitioner progress notes dated 08/03/21, revealed the wound to the posterior LLE measured 7.5 cm in length by 7 cm in width by 1.5 cm in depth. The wound was 90% slough and eschar and 10% granulation tissue. The wound was described as a Stage IV with muscle and tendon exposed with a large amount of serous drainage. A new wound treatment was ordered to apply Santyl, nickel thick to wound bed, cover with Alginate dampened with Metronidazole solution for odor control, cover with four-by-four gauze, abdominal pad and gauze wrap, change daily and as needed. Review of the wound nurse practitioner progress note dated 08/10/21, revealed the posterior Stage IV LLE wound measured 9.5 cm in length by 7 cm in width by 2.4 cm in depth. Muscle and tendon exposed with a large amount of serosanguinous exudate. T he wound was 60% eschar/slough with 15% granulation tissue. Post debridement, the wound increased to 3.5 cm in depth. No new treatment orders were issued. Interview on 08/17/21 at 1:30 P.M., with Licensed Practical Nurse (LPN) #201, stated Resident #21 had a leg brace which caused her wounds. Two unsuccessful attempts were made to interview Wound Certified Nurse Practitioner (WCNP) #70 on 08/18/21 at 3:46 P.M. and on 08/19/21 at 1:42 P.M. Observation on 08/17/21 at 1:35 P.M., revealed the pool noodle ordered to elevate the resident's heels off the bed was incorrectly placed under her knees instead of her ankles. Further observations on 08/17/21 at 4:15 P.M., and 4:26 P.M., on 08/18/21 at 8:02 A.M., and 08/19/21 at 8:14 A.M., revealed the pool noodle was incorrectly placed under the residents knees or lower posterior legs. Observations and interview on 08/17/21 at 4:26 P.M. with State Tested Nursing Assistant (STNA) #122, revealed the resident had pool noodles to keep her heels off the bed. The pool noodle was located under the resident's knees and not under her heels per the physician order. STNA #122 stated the noodle was placed between the mattress and the bed sheet then pillows on top of noodles. STNA #122 was unaware the noodle placement was incorrect. Observation on 08/18/21 at 10:11 A.M. of Resident #21's wound care, revealed LPN #201 completed wound care to the resident's left posterior lower leg. The wound bed was deep, oblong, and red with slough present. Muscle, tendon, and bone were visible. LPN #201 completed the wound treatment per physician orders. Interview on 08/18/21 at 12:43 P.M. with LPN #201, stated when she removed the resident's leg immobilizer on 06/25/21, she lifted the resident's leg and noticed the wound underneath. LPN #201 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 3 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 - Actual harm Residents Affected - Few during morning report, the previous shift had not reported any new skin areas. LPN #201 stated she measured the area. LPN #201 stated the wound had eschar and was dark. LPN #201 stated she notified the family, physician and the Director of Nursing. LPN #201 revealed the immobilizer skin integrity checks were not getting done correctly. LPN #201 revealed most likely the skin under the resident's leg was not getting checked as movement of the leg caused the resident discomfort. Interview on 08/18/21 at 1:12 P.M., with Registered Nurse (RN) #208, stated the resident had an unstageable pressure ulcer from her leg immobilizer. RN #208 could not recall any skin issues during the resident's skin checks. Interview on 08/18/21 at 2:37 P.M., with the Director of Nursing (DON), stated staff notified her of the wound. The DON stated she called the physician to assess the wound immediately. The DON stated the none of the nurses admitted to not checking the resident's skin. The DON stated some of the nurses stated the resident was agitated during the skin checks and they had not assessed the skin underneath the leg. The DON stated the nurses should have provided pain medication then completed the skin assessment. Continued interview with the DON, revealed prior to the wound discovery, the nurses had not reported they could not complete the skin inspections due to resident pain. The DON stated she educated the nurses regarding the immobilizer skin check procedures. The DON stated the education had not included a demonstration on how to check the skin under the immobilizer device. Interview on 08/19/21 at 8:14 A.M. with LPN #202, verified the pool noodle was placed under the resident's knees. LPN #202 reviewed the physician order and revealed the pool noodle should be placed under the resident's ankles and not her knees. Interview on 08/19/21 at 9:04 A.M., with Physician #80, indicated the wound on the resident's posterior leg was consistent with the edge of the leg immobilizer. Physician #80 further revealed he had not removed the resident's leg immobilizer during a visit on 06/17/21. Physician #80 further revealed he had not assessed the wound on 06/25/21. Interview on 08/19/21 at 9:31 A.M. with Corporate Clinical Registered Nurse (CCRN) #300, verified there was no documentation in the nurses notes the resident had refused to allow staff to remove the leg immobilizer to check skin integrity. CCRN #300 also verified the wound treatments to the resident's left leg were not completed on 07/03/21, 07/08/21 and 07/18/21. Review of a physician progress note addendum dated 08/19/21 at 10:31 A.M., revealed the physician was informed by the Administrator of a wound to the left lower leg, pressure from immobilizer. The physician noted the resident was in bed, as usual, flat on back. Painful for patient to have leg moved, wound was posterior and freshly dressed, so elected to rely on nursing's description of wound at that time. Area compatible with lower edge of immobilizer. Treatment orders given and ordered a wound consult. Review of the National Pressure Ulcer Advisory Panel (NPUAP) wound staging definitions revealed a Stage IV pressure injury was full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. An unstageable pressure injury was full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed as it obscured by slough or eschar. Review of the facility policy titled, Skin Management, dated 10/2019, revealed the facility should identify and implement interventions to prevent development of clinically unavoidable pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 4 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 injuries. Level of Harm - Actual harm 2. Review of the medical record for Resident #34 revealed a readmission date of 07/10/21. Diagnoses included chronic obstructive pulmonary disease, Type II diabetes, hypertension, major depression, anemia, and schizoaffective disorder. Residents Affected - Few Review of the admission nursing assessment identified Resident #34 was admitted with a Stage I pressure ulcer to the coccyx and one unstageable pressure area to the left heel. No other pressure ulcers were noted. The resident had a pressure reducing device for the bed with nutrition and hydration to manage. Review of the physician orders for 07/18/21, identified an order for a Prevalon boot to left the foot at all times. Review of the plan of care dated 07/20/21, revealed the resident had a pressure ulcer injury due to recent hospitalization, decreased mobility, and incontinence. Interventions included pressure reducing mattress to bed, and Prevalon boots to bilateral lower extremities at all times, may remove for ambulation and hygiene. Review of the wound monitoring sheets with onset date of 07/20/21, revealed the resident had an inhouse acquired deep tissue pressure injury on the right heel. The wound measured 1.1 centimeters (cm) by 1.1 cm by 0.0 cm deep. The wound bed was a deep tissue injury persistent non blanchable deep red, maroon or purple discoloration. Review of the wound monitoring sheets dated 07/28/21, revealed the resident had an inhouse acquired deep tissue pressure injury on the right heel. The wound measured 0.7 centimeters (cm) by 0.9 cm by 0.0 cm deep. The wound bed was deep tissue injury persistent non blanchable deep red, maroon or purple discoloration. Review of the wound monitoring sheets dated 08/10/21, revealed the resident had an inhouse acquired deep tissue pressure injury on the right heel. The wound measured 0.9 centimeters (cm) by 0.9 cm by 0.0 cm deep. The wound bed was deep tissue injury persistent non blanchable deep red, maroon or purple discoloration and treatment normal saline, no dressing applied. Review of the wound clinic note date 08/17/21, revealed bilateral heel wounds and right heel unstageable. The wound measured 1.0 centimeters (cm) by 1.5 cm by 0.0 cm deep. No undermining 100% epithelial. Recommended treatment to off load heels at all times with heel boot or with pillow. Interventions included Prevalon boot to bilateral feet at all times may remove for ambulation and hygiene per physician order. Observation on 08/17/21 at 8:20 A.M., of Resident #34, lying in bed on back without heel protectors. Licensed Practical Nurse (LPN) #201, verified the bilateral heel protectors were not on and heels were not offloaded. Interview on 08/17/21 at 8:39 A.M. with Resident #34, reported she doesn't know when she got the area on the heel, but heels were sore when lying in bed. Interview on 08/17/21 at 8:25 A.M. with Licensed Practical Nurse (LPN) #201, revealed the heel protectors were to be on at all times and remove for ambulation and hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 5 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/19/21 at 1:15 P.M., with Corporate Clinical Registered Nurse (CCRN) #300, revealed an order for the Prevalon boot for the right heel was not added to the MAR or TAR, as it was somehow missed. She also verified the wound measurement was not completed for the week of 08/01/21 to 08/07/21. Review of facility policy titled, Skin Management, dated 10/2019, revealed at risk heel suspension devices to be offloaded. Event ID: Facility ID: 365656 If continuation sheet Page 6 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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, observation, staff interview, and facility policy, the facility failed to ensure a resident's physician ordered fall precautions were in place. This affected one (#8) of three residents reviewed for accidents. The facility census was 43. Findings include: Review of Resident #8's medical record revealed an admission date of 12/09/14. Diagnoses included specified congenital malformation syndromes, epilepsy, cerebral palsy, congenital hydrocephalus, gastrostomy status, schizophrenia, psychotic disorder with hallucinations, and dysphagia. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE], listed the resident has having severe cognitive impairment. Review of Resident #8's care plan revealed the resident to be at risk for falls related to gait problems and history of falls. Interventions included mat to bedside. Review of Resident #8's physician orders revealed an order dated 08/01/21, for mat to the floor beside bed every shift. Observation on 08/17/21 at 3:19 P.M. of Resident #8, revealed the resident resting in bed with no floor mat beside the bed. Interview on 08/17/21 at 8:20 P.M. with Registered Nurse (RN) #300, verified Resident #8 did not have a floor mat as ordered beside the bed. Review of facility policy titled, Fall Management, dated July 2021, revealed, if a fall occurs, the interdisciplinary team will conduct an evaluation to ensure appropriate measures were in place to minimize the risk of future falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 7 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of employee records, staff interview and review of the facility policy, the facility failed to ensure annual performance evaluations had been completed for three (#133, #114 and #110) State Tested Nursing Assistants (STNA's). This affected three of five personal files reviewed and had the potential to affect 43 of 43 residents who reside in the facility. Residents Affected - Many Findings include: Review of the employee record for STNA #133, revealed a hire date of 08/18/20. Further review of the employee record revealed no performance evaluations had been completed in 2021. Review of the employee record for STNA #114, revealed a hire date of 01/12/10. Further review of the employee record revealed no performance evaluations had been completed in 2021. Review of the employee record for STNA #110, revealed a hire date of 04/14/15. Further review of the employee record revealed no performance evaluations had been completed in 2021. Interview on 07/12/21 at 3:50 P.M., with Human Resource (HR) #67, verified no performance evaluations had been completed for STNA #133, STNA #114 and STNA #110. Review of facility policy titled, Personnel File Checklist, dated 04/17, revealed employee files to include evaluations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 8 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 - Potential for minimal harm Residents Affected - Many 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 observations, staff interview, review of the facility policy and review of the manufacturer's recommendations, the facility failed to ensure medications were properly discarded. This had the potential to affect 43 of 43 residents who reside in the facility. Findings include: 1. Observations on 08/17/21 at 7:48 A.M. of the medication cart with Licensed Practical Nurse (LPN) #200, revealed numerous (approximately 40) unidentifiable loose pills in various compartments of the medication cart. LPN #200 confirmed the medications should be discarded and should not remain in the medication cart. LPN denied being aware the medications were in the cart. Further observation of medication cart revealed Resident #35's Lantus (insulin) was dated as being opened on 06/12/21 and Novolin (insulin) was dated as opened on 07/03/21. LPN stated insulin's should be discarded after thirty days of opening. LPN #200 further confirmed the residents Lantus was discontinued on 06/24/21, and the medication should have been discarded once it was discontinued. LPN #200 stated residents Novolin was an active order and insulin should have been discarded due to it being past thirty days since it had been opened. On 08/17/21 at 8:29 A.M., interview with the Director of Nursing (DON) confirmed the large amount of loose pills on LPN #200's medication cart. She stated medications should have been discarded and should not have remained on the cart. The DON further confirmed insulin's should be discarded thirty days after opening. 2. Observations on 08/18/21 at 8:35 A.M., of LPN #201's medication cart, revealed nine loose unidentifiable pills in various locations. LPN #201 stated medications should have been discarded and should not have remained loose in the medication cart. On 08/17/21 at 8:50 A.M., observation of the DON counting the loose pills from LPN #200's medication cart confirmed a total of 47 loose pills. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, dated 10/28/19, revealed a multi dose vial of injectable medication should be dated and discarded within 28 days unless the manufacturer specified a different date. Further review of policy revealed medications were to be stored in the containers in which they were originally received and the facility personnel should inspect nursing storage areas regularly for proper storage compliance. Review of the manufacturer's guidelines confirmed medication should be discarded 28 days after opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 9 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, review of the facility policy, the facility failed to ensure the food preparation area was maintained in a sanitary manner. This had the potential to affect 41 of 41 residents who receive meals from the kitchen. The facility identified two (#7 and #8) residents as not receiving meals from the kitchen. The facility census was 43. Findings include: Observation on 08/17/21 at 10:12 A.M. in the kitchen, revealed Dietary Manager #65 was pureeing roast beef. There was a window with an air conditioning unit blowing air directly into the food preparation area. Further observation of the air conditioning unit revealed a black substance was present above the vents on the air conditioner. There was a gap between the window frame and the air conditioner large enough to allow insects into the kitchen. The area around the window sill and air conditioning unit had a build up of dark brown dust. Additionally there were food stains on the wall and patches of repaired drywall not painted. Interview on 08/17/21 at 10:13 A.M., with DM #65, verified the air conditioner had a black substance on it and also verified the dust on the window sill. DM #65 pointed to the gap between the window and the air conditioner. DM #65 stated maintenance was responsible for cleaning the window and air conditioning area. Interview on 08/17/21 at 11:30 A.M. with DM #65, stated the drywall patches had remained unpainted for a long time. Review of the facility policy titled, Dietary Department Cleaning Schedule, dated 04/2010, revealed a schedule outlining cleaning assignments would be posted and completed to maintain the sanitation of the Dietary Department. The Dietary Manager or designee shall be responsible for updating, posting, and enforcing the Cleaning Schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 10 of 11 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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, observations, staff interview and review of the facility policy's, the facility failed to ensure the proper Protective Personal Equipment (PPE) was utilized when transporting residents who were in quarentine status to prevent the spread of COVID-19. This affected one (#193) of two residents reviewed for isolation precautions with a potential to affect 43 of 43 residents who reside in the facility. Residents Affected - Many Findings include: Review of the record for Resident #193 revealed an admission date of 08/09/21. Diagnoses included Type II diabetes, dysphagia, hypertension, major depression, metabolic encephalopathy and alcohol dependence with withdrawal. Observation on 08/16/21 at 10:22 A.M., of Resident #193, revealed signage noting the use of PPE for quarantine precautions with instructions on donning and doffing. The PPE was observed readily available outside of Resident #193's room. Observation on 08/16/21 at 10:24 A.M., of Activities Assistant (AA) #137, assisting Resident #193 down the hallway in a wheelchair from the room, revealed Resident #193 and AA #137 were wearing surgical face masks and no other personal protective equipment. Interview on 08/16/21 at 10:24 A.M., with Licensed Practical Nurse (LPN) #200, reported the resident was a new admission and was on a 14-day quarantine. She indicated Resident #193 was allowed out of his room to smoke. LPN #200 verified the resident and AA #137 were not wearing N95 mask, gown, gloves or face shield and continued down the hall to the front door to smoke. Interview on 08/18/21 at 2:09 P.M. with Licensed Social Worker (LSW) #400, revealed the resident has a right to smoke when on quarantine and were allowed to go out to smoke. She stated we put on PPE and staff were to wear an N95 mask. Review of the facility policy titled, Guest Smoking Policy, dated 07/30/20, revealed guest that wish to smoke and were on isolation precautions (quarantine precautions) due to new or readmission status, a separate designated smoking area will be identified by the facility for guests that wish to smoke while in isolation precautions (as a quarantine precaution). Review of the facility policy titled, Coronavirus (COVID 19), dated 03/2020, revealed all recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of N95 or higher respirator (or surgical if respiratory was not available), eye protection (goggles or face shield that covers the front and sides of the face), gloves and gown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365656 If continuation sheet Page 11 of 11