Inspection·August 16, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to properly monitor resident weights and failed to implement nutritional recommendations to prevent weight loss. This affected one (Resident #83) of three residents reviewed for nutrition. The facility census was 80 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #83 revealed an admission date of 05/07/24 with diagnoses including type two diabetes mellitus, anxiety disorder, and cerebral infarction, and a discharge date of 07/26/24. Review of the weight record for Resident #83 revealed the following weights: 05/07/24 -284 lbs., 05/14/24-310 lbs., 05/20/24-249.2 lbs., 06/03/24-248.7 lbs. Review of the care plan for Resident #83 dated 05/09/24 revealed the resident was unable to tolerate nutritionally adequate food and/or fluids by mouth and required the use of a feeding tube related to larynx cancer. Interventions included the following: administer tube feeding as ordered, staff to obtain weight at a minimum of monthly and report any significant weight changes to the physician and the dietician, staff to provide diet as ordered, staff to refer to dietician as needed. Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 05/14/24 revealed the resident had severe cognitive impairment, was dependent with toileting, bathing, dressing, and transfers and had a feeding tube. Review of the physician's orders for Resident #83 revealed an order dated 05/13/24 revealed for the resident to receive a tube feeding of Glucerna 1.5 at 80 milliliters (ml.) per hour (hr.) for 18 hours via pump with 240 ml of water every four hours. Review of the nutrition progress note for Resident #83 dated 06/05/24 revealed Resident #83 had a significant weight loss of 61.3 pounds, a 19.8 % loss from the weight dated 05/14/24 of 310 pounds. Further review of the note revealed the dietitian recommended Resident #83's tube feeding of Glucerna 1.5 to be increased from 80 ml./hr. to 95 ml./hr. and the total time of the feeding via pump to be increased from 18 hours to 20 hours. Review of the physician's orders for Resident #83 for June 2024 revealed there was no physician's order entered to increase the resident's tube feeding as recommended by the dietitian on 06/05/24. Review of the weight record for Resident #83 revealed the following weights: 05/07/24 -284 lbs., 05/14/24-310.4 lbs., 05/20/24-249.2 lbs., 06/03/24-248.7 lbs. Interview on 08/12/24 at 3:31 P.M. with Registered Dietician (RD) #50 confirmed Resident #83 weighed 284 lbs. upon admission on [DATE]. RD #50 confirmed Resident #83 weighed 310.4 lbs. on 05/14/24 which was a significant weight gain of 26.4 pounds, but the facility did not obtain a reweight to determine if this was a true weight gain. RD #50 confirmed Resident #83 weighed 249.2 lbs. on 05/20/24, which was a significant weight loss. RD #50 confirmed he was not the dietician for the facility on 05/20/24, but if he had been, he would have requested a reweight for Resident #83 on 05/20/24 and if the weight loss was accurate, he would have recommended an increase in the tube feeding at that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 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 365773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Kettering 694 Isaac Prugh Way Kettering, OH 45429 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time. RD #50 further confirmed Resident #83 was not weighed again till 06/01/24 and the resident's weight was 248.7 which was a significant weight loss of 61.3 pounds which was 19.8 % loss from 05/14/24 to 06/01/24. RD #50 confirmed the previous dietitian had documented a recommendation on 06/05/24 to increase the resident's tube feeding but it was never implemented. Review of the facility policy titled Weight Management dated 09/22/23 revealed residents would be monitored for significant weight changes on a regular basis. Residents were expected to maintain acceptable parameters of nutritional status. Any resident with unintended weight loss/gain would be evaluated by the interdisciplinary team and interventions would be implemented to prevent further weight loss/gain. Residents determined to be at risk or who had significant weight changes would be weighed on a weekly basis. Residents at risk included residents receiving total parental nutrition (TPN) for one month, newly tube fed residents, residents receiving a tube feeding with significant weight changes, or residents with insidious weight loss. This deficiency represents noncompliance investigated under Complaint Number OH00156362. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 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 365773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Kettering 694 Isaac Prugh Way Kettering, OH 45429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the medication error rate was less than five percent (%.) The facility medication error rate was 7.14% based on 28 medication opporunities and two medication errors. This affected two (Residents #22 and #68) of five residents reviewed for medication administration. The facility census was 80 residents. Residents Affected - Few Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 08/10/22 with diagnoses including type two diabetes mellitus (DM II), peripheral vascular disease (PVD), and anxiety disorder. Review of the physician's order for Resident #22 revealed an order dated 03/30/24 for the resident to received Refresh ophthalmic gel 1% instill one drop into both eyes two times a day for dry eyes. Observation on 08/07/24 at 8:24 A.M. of medication administration for Resident #22 per Registered Nurse (RN) #30 revealed the nurse did not administer Refresh ophthalmic gel 1% eye drops because the medication was not available. Interview on 08/07/24 at 8:31 A.M. with RN #30 confirmed Resident #22 had an order for Refresh ophthalmic gel 1% eye drops but they were not administered because the medication was not available. 2.Review of the medical record for Resident #68 revealed an admission date of 07/28/24 with diagnoses including malignant melanoma of skin, malignant neoplasm of brain, and obstructive and reflux uropathy. Review of the physician's orders for Resident #68 revealed an order dated 08/02/24 for Pradaxa (an anticoagulant medication) oral capsule 150 milligrams (mg) give one capsule by mouth every morning and at bedtime for 30 days. Observation on 08/07/24 at 8:42 A.M. of medication administration for Resident #68 per Licensed Practical Nurse (LPN) #20 revealed the nurse did not administer Pradaxa 150 mg because the medication was not available. Interview on 08/07/24 at 8:46 A.M. with LPN #20 confirmed Resident #68 had an order for Pradaxa 150 mg., but it was not administered because the medication was not available. Review of the facility policy titled Medication Administration dated 10/17/23 revealed resident medications were administered in an accurate, safe, timely, and sanitary manner. Medications were to be administered within 60 minutes of the scheduled time. This deficiency represents noncompliance investigated under Complaint Number OH00156756 and OH00156263. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 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 365773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Kettering 694 Isaac Prugh Way Kettering, OH 45429 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow proper infection control practices when providing direct care for residents with physician's orders for enhanced barrier precautions (EBP). This affected two (Residents #9 and #55) residents of three reviewed for infection control. The facility census was 80 residents. Residents Affected - Few Findings include: 1.Review of the medical record for Resident #9 revealed an admission date of 06/13/24 with diagnoses including hemiplegia affecting right dominant side, atrial fibrillation, and type two diabetes mellitus. Review of the physician's orders for Resident #9 revealed an order dated 07/05/24 for enhanced barrier precautions (EBP) due to the resident had the presence of a gastronomy tube (g-tube). Observation on 08/08/24 at 1:47 P.M. revealed State Tested Nurse Aide (STNA) #10 performed hand hygiene and applied gloves and assisted Resident #9 into bed and checked the resident's brief for signs of incontinence. STNA #10 did not don a gown during care for Resident #9. Interview on 08/08/24 at 1:50 P.M. with STNA #10 confirmed she did not wear a gown in Resident #9's room when providing care. Observation on 08/08/24 at 2:04 P.M. revealed Licensed Practical Nurse (LPN) #20 performed hand hygiene and applied gloves prior to g-tube care for Resident #9. LPN #20 did not don a gown during care for Resident #9. Interview on 08/08/24 at 2:30 P.M. with LPN #20 confirmed she did not wear a gown in Resident #9's room when providing care. 2. Review of the medical record for Resident #55 revealed an admission date of 07/15/24. Diagnoses included ileostomy status, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). Review of the physician's orders for Resident #55 revealed an order dated 07/15/24 for EBP related surgical incision and the presence of an ileostomy. Observation on 08/12/24 at 11:58 A.M. revealed STNA #14 performed hand hygiene and applied gloves prior to performing ileostomy care for Resident #55. STNA #14 did not don a gown during care for Resident #55. Interview on 08/12/24 at 12:06 P.M. with STNA #14 confirmed she did not wear a gown in Resident #55's room when providing care. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 03/26/24 revealed EBP were indicated for residents with any of the following: infection or colonization with a multidrug-resistant organism (MDRO) when contact precautions did not otherwise apply, a wound or indwelling medical device even if the resident was not known to be infected or colonized with a MDRO. Staff should use personal protective equipment (PPE) including gowns and gloves when providing care for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 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 365773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Kettering 694 Isaac Prugh Way Kettering, OH 45429 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 residents in EBP. Level of Harm - Minimal harm or potential for actual harm This deficiency represents noncompliance investigated under Complaint Number OH00156263 and OH00155935. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 6 of 6