Inspection·June 16, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some weight on 06/04/25, 06/06/25, 06/07/25, and 05/27/25, 05/21/25, 05/05/25. Review of TAR for May 2025, and June 2025 revealed the following weight changes, May 2025, a six-pound (lb.) weight gain on 05/22/25, a 9.6 lb. weight gain on 05/14/25, and a ten lb. weight gain on 05/28/25. June 2025, Resident #03 had a 19.8 lb. weight gain on 06/05/25. Further review of Resident #03's medical record revealed there was no documentation regarding physician notification regarding the resident's weight changes.Interview on 06/10/25 at 9:42 A.M. with Registered Dietician (RD) #500 confirmed the staff is supposed to inform the Nurse Practitioner (NP) of weight gain, loss, or missed weights. RD #500 stated she will email the Director of Nursing (DON) to make sure she saw the weight change. RD #500 confirmed verification of notification to the physician of the weight changes were not identified in the medical chart for Resident #03. RD #500 confirmed the importance of notification to the physician related weight changes to a possible fluid overload. Review of the facility policy titled, Weight Management Policy, dated 09/22/23, the Dietary Manager, Unit Manager, or Registered Dietician are to communicate weight changes to the Inter Disciplinary Team (IDT) team, attending physician, and responsible party. This is to be documented in the medical chart. 3. Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism.Review of the Minimum Data Set (MDS) for a Significant Change, dated 05/15/25, revealed Resident #53 received Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication, administration and personal hygiene. Resident #53 required staff to set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing. Review of the progress notes for Resident #53 revealed on 05/08/25 at 12:45 P.M. revealed the Social Worker (SW) #369 contacted the family to inquire about Hospice Services. The family agreed to a hospice consult verses a tube feed for Resident #53 related to significant weight loss. The family stated they would prefer to meet with a Hospice company. On 05/09/25 at 8:07 A.M. Resident #53's family notified the SW #369 that they chose to meet with a Hospice Company on 05/15/25 at 10:00 A.M. No other verification was identified in the progress notes to confirm Resident #53 had signed to receive hospice services or declined hospice services. Review of the Nutritional Care Plan for Resident #53 dated 05/08/25 revealed she was care planned for a need for Hospice Care for comfort care. Interview with the Regional Consultant Specialist (RCS) #402 on 06/10/25 at 10:44 A.M. confirmed the facility completed a Significant Change MDS for Resident # 53 because the facility thought Resident #53 signed with Hospice services when she met with them. However, Resident #53's family declined the services, and the facility failed to accurately document that Resident #53 does not have hospice. RCS #402 confirmed the facility failed to accurately code a MDS assessment. Interview on 06/10/25 at 10:45 A.M. with SW #369 confirmed Resident 5% of 5's family met with Hospice, however, the family determined they did not want to utilize hospice services. Interview on 06/10/25 at 9:42 A.M. with RD #500 confirmed at an IDT team meeting she recommended a hospice consultation for a feeding tube for Resident #53. RD #500 confirmed the facility failed to have a follow up meeting to discuss the fact that Resident #53's family declined hospice services. She confirmed no physician notification of the decline for hospice services was not documented. 4. Review of the medical record for Resident #19 revealed an admission date of 10/30/21 with diagnoses including multiple sclerosis and neuromuscular dysfunction of bladder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for toileting and required partial/moderate assistance with personal hygiene. Review of the medical record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 2 of 31 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 06/16/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete revealed Resident #19 had an indwelling urinary catheter. Further review of the medical record revealed Resident #19 had an order for Macrobid (antibiotic) on 06/09/25 for the treatment of a urinary tract infection (UTI). Review of urology progress notes dated 05/21/25, signed 05/29/25, for Resident #19 revealed an order to notify the urology Nurse Practitioner (NP) prior to obtaining urinalysis for suspected UTI, notify the urology NP for assessment/plan and necessity of sample, and to notify urology NP with any changes to urine output. Review of the medical record revealed no evidence of the resident's urology NP being notified of Resident #19's UTI. Further review of the medical record revealed on 06/03/25 the medical director requested Resident #19 follow up with urology. There was no further documentation regarding follow up with urology for Resident #19.Interview on 06/12/25 at 11:49 AM with Licensed Practical Nurse (LPN) #361 confirmed Resident #19's urology NP had not been notified of Resident #19's change of condition. LPN #361 further confirmed that on 06/03/25 the medical director requested Resident #19 follow up with urology but Resident #19 had not been seen by urology. Review of the facility policy titled Notification of Change, dated 02/14/24, revealed the licensed nurse will notify the resident's attending practitioner of changes in the resident status. Additionally, the licensed nurse will document in the resident electronic medical record the notification and the information that was provided, including any additional orders from the practitioner. Event ID: Facility ID: 365773 If continuation sheet Page 3 of 31 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 06/16/2025 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 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 record review, resident and staff interviews, and facility policy review, the facility failed to provide a homelike environment when meal trays were delivered to the residents with plasticware in place of silverware. This affected three Residents (#05, #67, and #129) out of three residents reviewed for home-like environment. The facility census was 76. Findings include: 1. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included hyperlipidemia, gastro-esophageal reflux disease, spinal stenosis, insomnia, essential hypertension, major depressive disorder, anorexia, anemia, and pruritus. Review of the Minimum Data Set (MDS) assessment, dated 05/12/25, revealed Resident #05 was cognitively intact. Further review of the MDS assessment revealed she was independent with eating. Review of the progress notes for Resident #05, 06/09/25 at 1:02 P.M. revealed Resident #05's daughter notified the staff that Resident #05's teeth were broken while eating pork chops on Sunday. Nurse Practitioner (NP) #510 confirmed the tooth was cracked but no swelling or redness was identified. Interview on 06/09/25 at 11:07 A.M. with Resident #05's daughter who was in the room with Resident #05. Resident #05's daughter stated Resident #05 broke her tooth on Sunday, 06/08/25 during her meal that consisted of pork chops. Resident #05's daughter stated her mother broke her tooth because the facility served the meal with plastic ware and her mother was unable to cut it and Resident #05's tooth was hanging inside her mouth. Interview with Resident #05 on 06/09/25 at 12:03 P.M. with Resident #05 revealed the facility served pork chops on 06/08/25 with plasticware in place of silverware. Resident #05 stated she was unable to cut the pork and had to try and chew it without cutting it. Resident #05 stated she broke her tooth, and her tooth was hanging and loose. Resident #05 stated she told her family but did not tell the facility because they wouldn't do anything about it. Interview and observation with Licensed Practical Nurse (LPN)#310 on 06/09/25 at 12:06 P.M. confirmed Resident #05 has a broken tooth hanging inside her mouth. Interview with dietary aide (DA) #396 on 06/12/25 at 8:16 A.M. confirmed the facility ran out of silver during mealtime on Sunday. DA #396 confirmed the facility had utilized plastic ware in place of silverware because the facility ran out of silverware. Interview with the Dietary Manager (DM) 348 on 06/11/25 at 7:41 A.M. confirmed the facility used plastic ware on Sunday, June 8, 2025. DM #348 confirmed he ordered replacement silverware in March 2025 when the Resident Council President informed him of the concern of the use of plasticware because the facility was short on silverware. DM#348 confirmed the facility does not have enough silverware to serve all the Residents with silverware at this time. DM#348 confirmed the facility served pork loin on Sunday 06/08/25 and the facility ran out of silverware on that date. Review of the facility menu dated Sunday, June 08, 25, confirmed the facility was scheduled to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 4 of 31 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 06/16/2025 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 0584 serve Pork Chops with sweet chili glaze, rice pilaf, roasted zucchini, and dinner roll with a pudding. Level of Harm - Minimal harm or potential for actual harm 2. Medical Record review for Resident #67 revealed she was admitted to the facility on [DATE]. Her diagnoses included acute kidney failure, diabetes mellitus (DM), hyperlipidemia, anemia, gastro-esophageal reflux disease (GERD), and osteomyelitis. Residents Affected - Few Review of the MDS assessment, dated 05/13/25, revealed Resident #67 was cognitively intact. Further review of the MDS assessment revealed Resident #67 was independent with eating. Interview on 06/09/25 at 11:04 A.M. with Resident #67 revealed she was upset that she was unable to eat her pork chop on Sunday, 06/08/25 because the facility served her meal with plasticware. Resident #67 stated she was so upset because she couldn't eat her meal, and her roommate (Resident #05) broke a tooth loose while trying to chew a pork chop with a plastic knife and fork. 3. Medical record review for Resident #129 revealed she was admitted to the facility on [DATE]. Her diagnoses included, essential primary hypertension, gastro-esophageal reflux disease (GERD), hyperlipidemia, chronic kidney disease, and ulcerative colitis. Review of the new admission assessment for Resident #129, dated 06/09/25, revealed she was independent with eating. Interview with Resident #129 on 06/09/25 at 11:45 A.M. revealed she arrived at the facility on 06/06/25 and was unhappy to see she was given plasticware on her meal tray. Resident #129 confirmed she had plasticware on her meal tray on Sunday, 06/08/25. Review of the facility, Resident Council Notes, dated 02/19/25 revealed the council ask the facility for more silverware. Review of the facility titled, Resident Rights, dated 05/14/24, confirmed the facility protects and promotes the rights of each resident and have the right to a dignified existence. The staff will assist the Residents in exercising their rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 5 of 31 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 06/16/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interviews, and policy reviews, the facility failed to complete a discharge summary or recapitulation of a resident's stay, failed to complete a bed hold notice when resident's were transferred to the hospital and failed to notify the Ombudsman of resident's discharges. This affected four (#15, #27, #75, and #134) out of four residents reviewed for discharges. The facility census was 76. Findings include: 1. Review of the medical record for Resident #134 revealed an admission date of 09/12/24 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, hypertensive heart disease, and malignant neoplasm of kidney. Review of the medical record revealed a discharge date of 01/23/25. Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MD'S) assessment, dated 12/20/24, which indicated Resident #134 was cognitively intact and was independent with activities of daily living. Review of the medical record for Resident #134 revealed a 72-hour care conference assessment which stated Resident #134 was undecided with discharge plans at this time and was homeless. The assessment stated Resident #134 stated she wanted to stay at the facility until he found housing or got a waiver to go to an Assisted Living. Review of the medical record for Resident #134 revealed a nurses' note, dated 11/25/24 at 12:41 P.M., which stated Resident #126 was issued a 30-day discharge notice due to nonpayment. The note stated Resident #126 verbalized he did not want his money to go to the facility as he had other bills such as storage and phone bill to pay monthly. Review of a Social Service (SS) note dated 01/20/25 at 4:11 P.M. which stated Social Service spoke with Resident #126 in regard to his discharge. The note stated Resident #134 stated he understood he would discharge to a hotel on 01/22/25. The note stated Resident #134 set up his own transportation along with the hotel booking. Review of the nurses' note, dated 01/22/25 at 6:44 P.M., stated Resident #134 discharged with his belongings, a copy of discharge summary, face sheet, and medication list. Review of the nurses' note dated 01/22/25 at 7:19 P.M. stated Resident #134 was unable to leave the facility due to his transportation never showed up and unable to go to the bank to get money for hotel. Further review revealed a Social Service note, dated 01/23/25 at 9:55 A.M. which stated Resident #134 discharged today to a hotel. Review of the medical record revealed a Discharge Notice for Non-payment, dated 11/25/24, which stated Resident #134 was to discharge to another nursing facility due to outstanding balance. Review of the medical record for Resident #134 revealed a Post Discharge Plan and Summary, dated 10/09/24 and signed as completed on 01/31/25. Further review of Resident #134's medical record revealed there was no documentation regarding a recapitulation of the residents stay. Review of the medical record for Resident #134 revealed no documentation to support the Ombudsman's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 6 of 31 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 06/16/2025 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 0628 office was notified his discharge. Level of Harm - Minimal harm or potential for actual harm Interview on 06/11/25 at 2:19 A.M. with Registered Nurse (RN) #387 confirmed the facility opens the Post Discharge Plan and Summary assessment upon a new resident admission. RN #387 confirmed Resident #134's assessment was signed after his discharge from the facility on 01/31/25. RN #387 confirmed there was no documented recapitulation of Resident #134's stay at the time of the discharge. Residents Affected - Some 3. Review of medical record for Resident #15 revealed an admission date of 02/12/24 with a discharge date of 05/28/25. Diagnoses included end stage renal disease (ESRD), atrial fibrillation, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, dressing, and transfers. Review of the progress note dated 05/25/25 at 2:02 P.M. revealed Resident #15 was unresponsive, hypertensive, and hypoglycemic and was sent to the hospital for evaluation. Review of the email notification to the Ombudsman dated 06/10/25 revealed all discharges from January through June 2025 were sent on 06/10/25. Interview on 06/11/25 at 8:03 A.M. with the interim Administrator revealed the previous Administrator was notifying the Ombudsman of discharged residents. The interim Administrator revealed there was a miscommunication with herself and social services where the notification to the Ombudsman was not getting completed. 4. Review of the medical record for Resident #75 revealed an admission date of 03/15/25 with a discharge date of 04/04/25. Diagnoses included type II diabetes mellitus (DM II), peripheral vascular disease (PVD), and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require independent with eating, setup with toileting, dependent with bathing, dressing, and transfers. Review of the progress note dated 04/04/25 at 4:33 P.M. revealed Resident #75's daughter called and stated an Uber would transport Resident #75 to the Veterans facility at 5:00 P.M. Resident #75 in agreement. Review of the email notification to the Ombudsman dated 06/10/25 revealed all discharges from January through June 2025 were sent on 06/10/25. Interview on 06/11/25 at 8:03 A.M. with the interim Administrator revealed the previous Administrator was notifying the Ombudsman of discharged residents. The interim Administrator revealed there was a miscommunication with herself and social services where the notification to the Ombudsman was not getting completed. Review of the facility policy titled, Transfer and Discharge, revised 04/22/25, stated the transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 7 of 31 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 06/16/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. The policy stated the criteria for transfer/discharge included the resident or representative failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident did not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his/her stay. The policy stated the notice of transfer/discharge must be made by the facility in writing at least 30 days before the resident was transferred or discharged and in a manner they understand. The policy stated exceptions to the 30-day requirement notice which must be made as soon as practicable before transfer or discharge. The policy stated that when an anticipated discharge is scheduled, the post-discharge plan of care and summary are developed prior to his/her discharge. The policy stated Social Services/designee reviews the plan with the resident and, with consent, the resident representative, at least 24 hours prior to discharge or as soon as practicable of the residents' discharge from the facility. When the facility anticipates discharge, a resident must have a discharge summary that includes a recapitulation of the resident's stay that includes, but was not limited to: 1) diagnoses, course of illness/treatment, therapy, and pertinent lab, radiology, and consultation results, 2) final summary of the resident's status, at the time of discharge, that is available for release to authorized personas and agencies, with the consent of the resident or resident representative, 3) reconciliation of all pre-discharged medications with the resident's post-discharge medications (both prescribed and over-the-counter), 4) post discharge plan of care and summary that was developed with the participate of the resident. The post discharge plan of care and summary must indicate where the individual plans to reside, an arrangement that has been made for the residents' follow-up care and any post-discharge medical and non-medical services. The policy also stated the transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. The transfer or discharge notice must contain the name, address, and telephone number of the office of the State of the Long-Term Care Ombudsman. This deficiency represents non-compliance investigated under Complaint Number OH00162817. 2. Medical record review for Resident #27 revealed she was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, cellulitis of left lower leg, essential primary hypertension, osteoporosis, hyperlipidemia, anemia, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. Resident #27 was dependent on staff for medication administration. She was independent with eating and required supervision with upper body dressing, personal hygiene. Resident #27 required maximum assistance with toilet use, bathing, and lower body dressing. Review of the progress notes for Resident #27 revealed she was discharged to the hospital on [DATE] and returned to the facility on [DATE] following a hospital stay. Nothing related to a bed hold notification was identified in the progress notes. Interview on 06/12/25 at 10:53 A.M. with the Business Office Manager (BOM) #357 confirmed the facility failed to provide Resident #27 a bed hold notice upon discharge to the hospital on [DATE]. Review of the facility policy titled, Bed Hold Policy, dated 02/14/22, confirmed the facility will contact the Resident or Responsible party regarding a bed hold. The facility will document the bed hold offer and the Resident/Responsible Party decision of the bed hold in the Resident's medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 8 of 31 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 06/16/2025 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 0628 record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 9 of 31 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 06/16/2025 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 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 record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate coded. This affected one (#53) out of three residents reviewed for MDS accuracy. The facility census was 76. Residents Affected - Few Findings include: Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism. Review of the Minimum Data Set (MDS) for a Significant Change, dated 05/15/25, revealed Resident #53 required Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication administration and personal hygiene. Resident #53 required staff set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing. Review of the progress notes for Resident #53 revealed on 05/08/25 at 12:45 P.M. revealed the Social Worker (SW) #369 contacted the family to inquire if the family would want to met with a Hospice Company for a consult or a tube feed was recommended by the dietician related to significant weight loss. The family stated they would prefer to meet with a Hospice company. On 05/09/25 at 8:07 A.M. Resident #53's family notified the SW #36 chose to meet with a Hospice Company on 05/15/25 at 10:00 A.M. No other information was documented related to the Hospice order or consult. Review of the Nutritional Care Plan for Resident #53, dated 05/08/25 revealed she was care planned for a need for Hospice Care for comfort care. Interview with the Regional Consultant Specialist (RCS) #402 on 06/10/25 at 10:44 A.M. confirmed the facility completed a Significant Change MDS for Resident #53 because the facility thought Resident #53 signed with Hospice services when she met with them. However, RCS #402 confirmed Resident #53's family declined the services and the facility failed to accurately document that Resident #53 does not have hospice. RCS #402 confirmed the facility failed to accurately code a MDS assessment. Review of the facility policy titled, Accuracy of MDS, dated 02/22/23, confirmed the accuracy of the MDS must be verified to ensure that the Residents strengths, weaknesses, status, and areas of actual decline or risk of decline are addressed to provide quality of care and to develop the individualized plan of care for the resident. Further review of the policy confirmed accuracy is also necessary as the MDS is directly responsible and like the Medicare Prospective Payment System, state Medicaid reimbursement programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 10 of 31 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 06/16/2025 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 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, observation, staff and resident interviews, and policy review, the facility failed to ensure a comprehensive skin assessment was completed upon admission. This affected one (#126) out of six residents reviewed for skin breakdown. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #126 revealed an admission date of 06/07/25 with medical diagnoses of cystitis, hypothyroidism, anemia, congestive heart failure, and chronic obstructive pulmonary disease. Review of the medical record for Resident #126 revealed a nursing comprehensive evaluation, dated 06/07/25, which indicated Resident #126 had a surgical incision to her back which measured 20 centimeters (cm) and had 58 staples. Further review of the evaluation revealed Resident #126 had bruising to right and left iliac crests and left antecubital, and a scab to right deltoid. Review of the medical record for Resident #126 revealed a Brief Interview for Mental Status (BIMS), dated 06/09/25, which indicated Resident #126 had moderately impaired cognition. Review of the medical record for Resident #126 revealed a nurses' note, dated 06/09/25 at 3:19 P.M. which stated notified of skin tear observed on right forearm that was present upon admission and measured 3 cm by 1.5 cm. The note stated no treatment was necessary at this time. Observation with interview on 06/09/25 at 3:03 P.M. with Resident #126 revealed a foam dressing located on right forearm which was dated 06/01/25. Resident #126 stated the dressing was applied to her arm at the hospital and wasn't sure what was under the dressing. Interview on 03/09/25 at 3:09 P.M. with Registered Nurse (RN) #358 confirmed the medical record for Resident #126 did not have documentation to support the facility assessed the skin issue to Resident #126's right forearm and that the dressing was dated 06/01/25. RN #358 stated he evaluated Resident #126's right forearm on 06/09/25 and observed a small skin tear to the forearm. RN #358 stated the area was scabbed over and no treatment was required. Review of the policy titled, Skin Management, reviewed 08/14/24, stated the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy stated upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record. The policy stated residents admitted with any skin impairment would have appropriate interventions implemented to promote healing, a physician's order for treatment, and skin impairment location, measurements, and characteristics documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 11 of 31 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 06/16/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on medical record review, observations, staff interviews, facility policy reviews, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify a resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Resident #35, who developed pressure ulcers while in the facility, which were not identified until they had reached an advanced stage. Resident #35 was noted to have a reddened area on 01/14/25, according to shower sheets, but the area was not assessed, and interventions were not implemented until 01/16/25 when the pressure ulcer was identified as an unstageable pressure ulcer (sloughing and/or eschar) to the coccyx. This affected one (#35) of five residents reviewed for pressure ulcers. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/15/24. Diagnoses included heart failure, dementia, delusional disorders, and anxiety disorder. Review of the care plan, dated 02/01/25, revealed Resident #35 had actual impaired skin integrity related to a pressure injury at stage three to the coccyx with excoriation noted to the peri-area. Interventions included: conduct skin assessment weekly, measure area and document characteristics, observe for signs of infection, apply enhanced barrier precautions (EBP), report abnormal findings to the physician, obtain labs as ordered, refer to the dietician as needed, and administer treatments as ordered. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/07/25, revealed Resident #35 had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require supervision with eating, and was dependent on staff for toileting, bathing, dressing, and transfers. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 01/04/25, revealed Resident #35 was at moderate risk. Review of the bathing task log, dated January 2025, revealed, on 01/14/25, Resident #35 was noted to have a reddened area. There was no further documentation or assessment of the reddened area. Review of a nursing progress note, dated 01/16/25 at 7:20 A.M., revealed Resident #35 had a new area noted to the coccyx with drainage noted. All required parties were notified. Review of the skin and wound evaluation, dated 01/16/25, revealed Resident #35 had an in-house acquired unstageable pressure ulcer to the coccyx, which measured 11.1 centimeters (cm) in length by 5.9 cm in width. Review of the physician order, dated 01/17/25, revealed Resident #35 was ordered a low air loss mattress (LAL) to the bed every shift. Review of the physician orders for Resident #35, dated 01/17/25, revealed orders to cleanse the coccyx with wound cleanser, pat dry, apply zinc oxide cream and cover with bordered gauze every shift. Review of a nursing progress note, dated 01/20/25 at 5:10 P.M., revealed Resident #35 was seen by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 12 of 31 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 06/16/2025 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 0686 the in-house wound provider with new orders for treatment to cleanse area with dermal wound cleanser, pat dry, apply impregnated gauze, cover with bordered gauze dressing. Level of Harm - Actual harm Residents Affected - Few Review of the physician progress note, dated 01/23/25, revealed Resident #35 was noted to have a stage three pressure ulcer on coccyx and was being followed by in-house wound care. Review of the physician orders for Resident #35, dated 01/27/25, revealed orders for an oral multivitamin-minerals tablet once a day. Interview on 06/10/25 at 1:03 P.M. with Certified Nursing Assistant (CNA) #399 revealed Resident #35 had an area to her coccyx that she reported to the night shift nurse on 01/14/25. Interview on 06/10/25 at 2:07 P.M. with Registered Nurse (RN) #388 revealed he could not recall if CNA #399 reported any skin concerns regarding Resident #35 on 01/14/25. Interview on 06/11/25 at 8:32 A.M. with Assistant Director of Nursing (ADON) #387 revealed CNA's were expected to report any new skin findings to their nurse immediately. ADON #387 stated the nurse was responsible for assessing the area, completing a nursing progress note, and a change in condition template. All new skin areas, that were noted in the medical record, popped up on the resident's dashboard, which was managed by the interdisciplinary team (IDT) the following day. ADON #387 verified Resident #35's new skin concern was missed. Interview on 06/11/25 with Licensed Practical Nurse (LPN) #304 revealed she noted the area on Resident #35's coccyx on 01/16/25. The area was open with yellow and bloody drainage. LPN #304 could not recall how big the area was at that time. Interview on 06/11/25 at 4:21 P.M. with ADON #387 verified no further assessment, treatments or interventions were put into place for Resident #35 on 01/14/25, when the reddened area was noted. ADON #387 reported a progress note was written and a treatment was initiated on 01/16/25. ADON #387 further explained Resident #35 was at high risk for the development of pressure ulcers due to a previous stage three pressure ulcer on the left heel. Interview on 06/12/25 at 10:02 A.M. with Wound Physician Assistant (WPA) #502 verified Resident #35 presented with an area to the bilateral buttocks, as an unstageable pressure ulcer. WPA #502 stated Resident #35 was incontinent, had a urinary tract infection (UTI), and was dependent on staff for activities of daily living (ADL), which all played a role in the development of the unstageable pressure ulcer. Observation on 06/12/25 at 10:48 A.M. revealed Resident #35's peri wound to the coccyx was reddened and appeared to be the size of a softball. The wound bed was approximately a dime size in width, with no signs of infection or drainage noted. Review of the NPUAP guidelines, dated 2014, at pages 70-71 (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 13 of 31 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 06/16/2025 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 0686 Level of Harm - Actual harm Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 14 of 31 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 06/16/2025 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 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 record review, observation, resident and staff interviews, and facility policy review, the facility failed to ensure fall interventions were in place as care planned. This affected one (#31) out of one resident reviewed for falls. The facility census was 76.Findings include:Medical record review for Resident #31 revealed she was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, cellulitis of left lower limb, heart failure, essential primary hypertension, hyperlipidemia, and anemia. Review of the Minimum Data Set (MDS) assessment for Resident #31, dated 03/12/25, revealed she was cognitively intact. Resident #31 was dependent on staff for medication administration, oral hygiene, toilet use, bathing, personal hygiene, dressing, and transfers. She required moderate assistance from staff with eating. Resident #31 required the use of a wheelchair for mobility. Review of the, Fall Care Plan, initiated on 05/28/25, for Resident #31 revealed she was care planned to have the following interventions in place to aide the prevention of future falls. On 06/05/25 the facility added parameter mattress to help with positioning, administer medications as ordered, anticipate needs, encourage to head of the bed lowered, encouraged to sleep at a 90 degree angle, encourage Resident #31 to wear nonskid socks, keep bed in the lowest position, encourage toilet use every two to three hours, ensure bolsters on bilateral sides, keep environment safe, lock wheels on wheelchair, provide resident with activities that minimize the potential for falls, Physical therapy and occupational therapy to evaluate as needed, encourage resident to use call light for assistance. Review of Resident #31's progress notes revealed an Inter Disciplinary Team (IDT) noted, 05/29/25 revealed on 03/12/25 at 7:50 P.M. Resident #31 was found on the floor after she attempted to transfer herself. The intervention was to remind the Resident to use call light before Resident #31 transfers from the bed and wear proper footwear. On 03/27/25 at 3:45 A.M. Resident #31 was found on the floor from the bed and no intervention was listed in the progress notes. On 04/02/25 at 2:40 A.M. Resident #31 was found on the floor. The intervention was to add bolster pillows to both sides of the bed. On 04/21/25 at 6:15 A.M. Resident #31 had a fall from bed. Resident #31 rolled out of bed on the left side and the intervention was to lower her head while she was in bed. On 05/28/25 at 2:05 P.M. from in her bed in front of her nightstand. The intervention was to have her bed in the lowest position. Review of the facility reports titled, Fall Investigation, dated 06/04/25 at 21:45 P.M., for Resident #31 revealed she was found on the floor. She was found on her left side and back to her door. Resident #31 stated she falls out of bed when sleeping. The fall intervention was a perimeter mattress. Review of the fall investigation dated 05/28/25 at 2:05 P.M., for Resident #31 revealed she was found on the floor. Resident #31 was observed on her left side of her bed in front of the nightstand. Resident #31 was identified as having non-gripper socks on. Resident #31 had a bruise on her right knee. The intervention was listed as encourage Resident #31 to have her bed in the lowest position to help prevent injuries. Review of the fall investigation dated 04/21/25 at 6:15 P.M., for Resident #31 revealed she was found on the floor and the left side of her head next to the bed and facing the bed. The resident had a golf ball size bump on the top of her head. Resident #31 was determined to have bed height not appropriate. The intervention was listed as head of bed all the way up while patient sleeping, encourage resident to lower head of bed (HOB) when sleeping. Review of the fall investigation dated 03/27/25 at 3:45 P.M. revealed Resident #31 called for assistance and Resident was agitated. Review of the fall investigation revealed the intervention was to encourage toileting every three hours and keep wheels locked bedside. Review of the fall investigation, dated 03/12/25 at 17:50 P.M. revealed Resident # 31 was found on the floor. Resident #31 was unable to give a description (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 15 of 31 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 06/16/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the fall. The intervention was listed to use call light for assistance with transfers and non-skid socks. Interview on 06/09/25 at 4:27 P.M. with Resident #31 revealed she has had about six falls since her admission. Resident #31 stated the falls happen when she is in bed. Resident #31 was observed lying in her bed with no bolsters or parameter mattress. Resident #31 was lying on a regular air mattress. Interview and observation on 06/11/25 at 2:30 P.M. interview with Licensed Practical Nurse (LPN) #385 confirmed Resident #31 should be on a bolstered mattress and is not. Interview on 06/11/25 at 5:05 P.M. with the Director of Nursing (DON) confirmed the fall intervention for Resident #31 was a bolstered mattress. The DON stated she ordered this specialized mattress herself. The DON contacted the representative from the mattress company and the representative from the mattress company explained the mattress had been delivered but the bolsters were not inflated because the company will not inflate the bolsters without a physician order. Interview on 06/11/25 at 5:11 P.M. with the Assistant Director of Nursing (ADON) #12 confirmed Resident #31 did not have bolstered mattress on her bed and that the facility did not have a physician's orders in place for a bolstered mattress. Review of the facility policy titled, Fall Management, dated 09/22/23, confirmed the facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Further review of the policy revealed interventions should be related to the risk factors as well as incorporation of resident choice to help minimize the risk of a fall. The Inter Disciplinary Team (IDT) team will review and modify the plan of care to minimize repeat falls. Event ID: Facility ID: 365773 If continuation sheet Page 16 of 31 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 06/16/2025 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 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** 3. Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Residents Affected - Few Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the medical record for weights for Resident #2 revealed the following: 02/28/25: 221.1 pounds 03/01/25: 289.4 pounds 03/02/25: 289.4 pounds 03/11/25: 388.2 pounds 03/18/25: 388.1 pounds 03/25/25: 387.2 pounds 03/26/25: 244 pounds 04/01/25: 285.6 pounds 04/04/25: 285.5 pounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 17 of 31 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 06/16/2025 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 05/05/25: 285.5 pounds - Residents Affected - Few 06/11/25: 237.6 pounds Review of the medical record for Resident #2 since admission revealed weights were inconsistent with no notification to the physician of significant weight loss and weight gain. Review of the progress note dated 03/12/25 at 2:04 P.M. revealed Resident #2 had a 99-pound weight gain in one week. Reviewed with IDT. Recommended to recheck weekly weight and continue to follow. Review of the progress note dated 03/21/25 at 4:11 P.M. revealed Resident #2's current weight consistent with previous weight obtained, which was a 99-pound weight gain in two weeks. Reviewed with IDT and questioned difference in scales that were used. Continue to monitor and follow. Review of the progress note dated 04/04/25 at 3:47 P.M. revealed Resident #2 continued with weight fluctuations since admission. Suspected weights of 380 pounds were in error and weight variations were likely different methods to obtain weight. Interview on 06/11/25 at 9:42 A.M. with Registered Dietician (RD) #500 reported concerns inconsistencies with weights. RD #500 stated she had brought this to the facility's attention because of her concerns with not obtaining accurate weights. RD #500 explained the facility was working on fixing this problem and tried calibrating scales and educating staff. RD #500 verified Resident #2 had a significant weight change from May to June, which she would be following up on and making recommendations. Review of the facility policy titled, Weight Management, revised 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, such as usual body weight and protein levels. Any resident with unintended weight loss/gain would be evaluated by the interdisciplinary team (IDT) and interventions would be implemented to prevent further weight loss/gain. Re-weights were initiated for a five-pound variance if greater than 100 pounds and for a three-pound variance if less than 100 pounds. If a resident's weight was greater than 200 pounds, a re-weight would be done for a weight loss or gain of three percent. Re-weights would be done within 48-72 hours. Based on record review, interview, and facility policy review, the facility failed to adequately monitor weights and/or implement appropriate interventions for residents who experienced significant weight loss. This affected three (03, #53, #2) out of three residents reviewed for nutrition/weight monitoring. The facility census was 76. Findings include: 1. Medical record review for Resident #03 revealed she was admitted to the facility on [DATE]. Her diagnoses included gastro-esophageal reflux disease (GERD), atrial fibrillation, borderline personality disorder, osteoarthritis of knee, congestive heart failure (CHF), anemia, edema, major depressive disorder, and obstructive sleep apnea. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 18 of 31 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 06/16/2025 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 Review of the Minimum Data Set (MDS) assessment, dated 05/20/25, revealed Resident #03 was cognitively impaired. Resident #03 was dependent on staff for medication administration, and lower body dressing. She was independent with eating, she required assistance with oral hygiene, and maximum assistance from staff with toilet use. She required moderate assistance from staff with showers, and personal hygiene. Residents Affected - Few Review of the progress notes, dated 05/21/25, revealed a weight warning. It stated weight fluctuations on the daily weight monitor, Resident #03 received a No Added Salt (NAS) diet, regular textures, thin liquids, and 2000 milliliter (ml) fluid restriction. Resident #03 meal intakes are 51% to 100% on the current diet. No recommendations were identified. No notification to the physician was identified. Review of the progress notes, dated 06/06/25, revealed a weight warning of 5.0% in thirty days, the notes stated it was reviewed with the Interdisciplinary Team (IDT) team, however, no indication of physician or family notification. Review of the physician orders for Resident #03 revealed an order, dated 11/22/24, for daily weight every day shift related to congestive heart failure (CHF). Review of the Treatment Administration Record (TAR) for Resident #03, dated May 2025, and June 2025, revealed the facility failed to obtain a daily weight on 06/04/25, 06/06/25, 06/07/25, and 05/27/25, 05/21/25, 05/05/25. Review of TAR for May 2025, and June 2025 revealed the following weight changes, May 2025, a six-pound (lb.) weight gain on 05/22/25, a 9.6 lb. weight gain on 05/14/25, and a ten lb. weight gain on 05/28/25. June 2025, Resident #03 had a 19.8 lb. weight gain on 06/05/25. Interview on 06/10/25 at 9:42 A.M. with Registered Dietician (RD) 500 confirmed the staff is supposed to inform the Nurse Practitioner (NP) of weight gain, loss, or missed weights. RD #500 stated she will email the Director of Nursing (DON) to make sure she saw the weight change for Resident #03. RD #500 confirmed verification of notification to the physician of the weight changes were not identified in the medical chart for Resident #03. RD #500 confirmed the importance of notification to the physician related weight changes to a possible fluid overload. Review of the facility policy titled, Weight Management Policy, dated 09/22/23, the Dietary Manager, Unit Manager, or Registered Dietician are to communicate weight changes to the IDT team, attending physician, and responsible party. This is to be documented in the medical chart. 2. Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism. Review of the MDS for a Significant Change, dated 05/15/25, revealed Resident #53 received Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication, administration and personal hygiene. Resident #53 required staff to set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing. Review of the progress notes for Resident #53 revealed on 05/08/25 at 12:45 P.M. revealed the Social Worker (SW) #369 contacted the family to inquire about Hospice Services. The family agreed to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 19 of 31 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 06/16/2025 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 hospice consult verses a tube feed for Resident #53 related to significant weight loss. The family stated they would prefer to meet with a Hospice company. On 05/09/25 at 8:07 A.M. Resident #53's family notified the SW #369 that they chose to meet with a Hospice Company on 05/15/25 at 10:00 A.M. No other verification was identified in the progress notes to confirm Resident #53 had signed with hospice services or declined hospice services. Residents Affected - Few Review of the Nutritional Care Plan for Resident #53 dated 05/08/25 revealed she was care planned for a need for Hospice Care for comfort care. Interview with the Regional Consultant Specialist (RCS) 402 on 06/10/25 at 10:44 A.M. confirmed the facility completed a Significant Change MDS for Resident #53 because the facility thought Resident #53 signed with hospice services when she met with them. However, Resident #53's family declined the services, and the facility failed to accurately document that Resident #53 does not have hospice. RCS #402 confirmed the facility failed to accurately code a MDS assessment as the resident is not receiving hospice services. Interview on 06/10/25 at 10:45 A.M. with SW #369 confirmed Resident #53's family met with hospice, however, the family determined they did not want to utilize hospice services. Interview on 06/10/25 at 9:42 A.M. with RD #500 confirmed at an IDT team meeting she recommended a hospice consultation for a feeding tube for Resident #53. RD #500 confirmed the facility failed to have a follow up meeting to discuss the fact that Resident #53's family declined hospice services. RD #500 confirmed no further nutritional assessments or interventions were implemented when Resident #53's family declined hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 20 of 31 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 06/16/2025 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 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 review of the medical record, interviews, and policy review, the facility failed to timely implement appropriate interventions to manage a resident's pain. This affected one (#2) of five reviewed for pain management. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 02/28/25 revealed Resident #2 was at risk for pain related to decreased mobility, chronic pain, MS, and generalized pain. Interventions included anticipate need for pain relief, notify physician if interventions were unsuccessful, observe and report non-verbal pain, observe and record loss of appetite, and offer non-pharmacological interventions. Review of the physician progress note dated 03/08/25 revealed pain was being managed with Tizanidine, Gabapentin, Baclofen, and Tylenol. Review of the progress note dated 04/01/25 at 5:14 P.M. revealed Resident #2 refused Tylenol because it did not help pain. Review of the progress note dated 04/08/25 at 12:27 A.M. revealed Resident #2 refused Tylenol because it did not work for him. Review of the progress note dated 05/30/25 at 3:33 P.M. revealed Resident #2 refused Tylenol because it did not help with his pain. Review of the progress note dated 06/09/25 at 4:42 P.M. revealed Resident #2 requested an increase in pain medication. Physician was called and received new order for Gabapentin 100 milligrams (mg), give one capsule by mouth three times a day. Interview on 06/09/25 at 12:51 P.M. with Resident #2 revealed he was on Tizanidine 4 milligrams (mg) three times a day (TID), Baclofen 30 mg TID, and Gabapentin 200 mg TID, but the only medication he was currently on was Baclofen 10 mg TID. Resident #2 reported he had told staff he needed those medications for his MS but no one ever followed up. Interview on 06/12/25 at 7:55 A.M. with Assistant Director of Nursing (ADON) #387 verified Resident #2 was supposed to be seen by neurology in May but due to transportation issues, he was not seen. ADON #387 verified a follow-up concerns medications was not completed. Interview on 06/12/25 at 8:50 A.M. with ADON #387 verified the physician had been documenting in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 21 of 31 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 06/16/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete his progress notes that Resident #2 was receiving Tizanidine, Gabapentin, Baclofen, and Tylenol, which was incorrect and the inconsistency was not addressed with the physician. ADON #387 confirmed staff did not address the Resident #2's complaints of pain and that Tylenol was ineffective. Review of the facility policy titled, Pain Management, dated 03/05/25 revealed the facility would evaluate and identify residents for pain, determine the type, location, and severity and develop a care plan for pain management. The licensed nurse would communicate any new onset of resident pain or change in resident pain to the physician and to the interdisciplinary team (IDT) through the 24-hour report/dashboard process. Event ID: Facility ID: 365773 If continuation sheet Page 22 of 31 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 06/16/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to assess a dialysis access site as per facility policy. This affected one (#132) out of one resident reviewed for dialysis. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #132 revealed an admission date of 06/03/25 with medical diagnoses of cervical disc degeneration, end stage renal disease (ESRD), dependence on dialysis, hypertension, and diabetes mellitus. Review of the medical record for Resident #132 revealed a nursing comprehensive evaluation, dated 06/03/25, which indicated Resident #132 was alert and oriented to person and place. The evaluation also indicated Resident #132 admitted with a fistula to left forearm. Review of the medical record for Resident #132 revealed no documentation to support the facility had assessed Resident #132's dialysis fistula to his left forearm. Interview on 06/11/25 at 8:30 A.M. with Director of Nursing (DON) confirmed the facility did not have documentation to support Resident #132's fistula to left forearm had been assessed since admission. DON confirmed nursing staff were to assess the fistula daily per the facility policy. Review of the facility policy titled, Hemodialysis, revised 03/05/24 stated residents receiving hemodialysis would be evaluated pre and post treatment and receive necessary interventions. The policy stated the facility completed the appropriate section of the hemodialysis form prior to the resident receiving each dialysis session and again when the resident returns from hemodialysis. The policy also stated the facility is to evaluate the resident daily for dialysis access site and possible complications, for thrill and bruit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 23 of 31 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 06/16/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide behavioral health services for Resident #14 who had diagnoses of mental disorders. This affected one (#14) of six residents reviewed for behavior management. The facility census was 76. Findings include: Review of the medical record for Resident #14 revealed an admissions date of 05/07/25 with diagnoses including bipolar disorder, anxiety disorder, recurrent depressive disorder, opioid dependence, and schizoaffective disorder. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #14 was cognitively intact. Review of Resident #14's orders revealed the resident had a physician order on 05/07/25 for a psychiatric evaluation and treatment. Review of the care plan, dated 05/28/25, revealed that Resident #14 had a history of behavior problems. Interventions include administer medications as ordered, reporting abnormal finding to the physician, approach in a calm manner, observe behavior episodes and attempt to determine underlying cause, and consult psychology as needed. Further review of the care plan, dated 05/28/25, revealed that Resident #14 had a history of not following treatment regimen. Interventions include allowing resident to make decisions about the treatment regime to provide sense of control, approaching resident in a calm manner, and praise resident when behaviors are appropriate. Review of Resident #14's nursing progress note, dated 05/09/25, revealed that she refused morning incontinence care. Review of Resident #14's nursing progress note, dated 05/13/25 revealed that she refused incontinence care. Further review revealed that she told aides to not touch her, to get out of her room and leave her alone. Review of Resident #14's social services progress note, dated 05/14/25, revealed that Resident #14 stated she does not have mood or behavior concerns. Further review of the note revealed that the facility has observed Resident #14 showing behaviors including yelling, screaming and refusing care multiple times a day. Review of Resident #14's nursing progress note, dated 05/15/25, revealed that she refused incontinence care in the morning. Review of Resident #14's behavior progress note, dated 05/25/25, revealed she was requesting pain medication prior to the next available dose. Resident #14 verbalized to the nurse and aide that she would report the nurse for not giving her medication. Physician and Director of Nursing were both notified of Resident #14's behavior. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 24 of 31 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 06/16/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Review of Resident #14's behavior progress note, dated 05/25/25, revealed Resident #14 was aggressive to the nurse when delivering as needed pain medication. Resident #14 was educated that medication may only be administer per physicians orders. Resident #14 stated that she should be able to choose when she receives medication. Physician was notified of behaviors. It was noted that two staff members will be present for future interactions to avoid incidents. Residents Affected - Few Review of Resident #14's physical therapy summary note, dated 05/27/25, revealed Resident #14 was screaming loudly the majority of session. Resident #14 was forcing poop out of her rectum on a few occasions as a form of a tantrum. Resident #14 closed fist punched and open hand slapped physical therapist and aide countless times on arms, chest, and abdomen regions. Resident #14 pull her gown up in hallways and was slapping the physical therapists when he tried to comfort her and help recover her dignity by rolling the gown safely back down. Resident #14 also rammed her wheelchair foot pedals and wheelchair into aides shins repetitively when aide was trying to move around her. Resident #14 was noted to be very emotionally and physically abusive throughout entire therapy session. Review of Resident #14's social services progress note, dated 05/27/25, revealed the resident punched therapist and aide in the chest and arms multiple times. Further review of the progress note revealed that Resident #14 refused to take medication. A pink slip was given to Resident #14 and she was sent to the emergency room by ambulance. Review of the pink slip revealed that Resident #14 represents a substantial risk of physical harm to others and would benefit from treatment in a hospital for her mental illness. Review of Resident #14's nursing progress note, dated 05/28/25, revealed she was returned to the facility by stretcher with no signs of distress and was cleared by the psychology doctor. Review of Resident #14's nursing progress note, dated 06/02/25, revealed she was found in her room playing in her bowel movement. The nurse educated Resident #14 to press the call light when she needed changed. Review of Resident #14's nursing progress note, dated 06/12/25, revealed Resident #14 requested her as needed inhaler. When the nurse brought her inhaler, the resident took the inhaler and self administered two puffs. The nurse then requested the inhaler back and Resident #14 refused, took 2 more puffs and stated that she would take as many puffs as she wants. Resident then asked for her as needed pain medication and the nurse informed her that she could not administer the medication for another hour. Resident #14 began yelling at the nurse for refusing to administer the pain medication early. Interview with Administrator on 06/12/25 at 2:48 P.M. verified that Resident #14 has not received psychology evaluation or treatment since receiving the physician order on 05/07/25. Review of the policy titled, Behavior Management, dated 04/20/23, revealed the facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 25 of 31 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 06/16/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered which resulted in a significant medication error. This affected one (#135) out of six residents reviewed for medication administration. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #135 revealed an admission date of 02/09/25 with medical diagnoses of encounter for other orthopedic aftercare, arthrodesis, left above the knee amputation, and aftercare following joint surgery. Review of the medical record revealed a discharge date of 03/11/25. Review of the medical record for Resident #135 revealed an admission Minimum Data Set (MDS) assessment, dated 02/15/25, which indicated Resident #135 was cognitively intact and required supervision with activities of daily living. Review of the medical record for Resident #135 revealed physician orders dated 02/09/25 for oxycodone 10 milligram (mg) one tablet by mouth six times per day and oxycodone 5 mg one tablet by mouth every six hours as needed (PRN). Review of the medical record for Resident #135 revealed the February 2025 Medication Administration Record (MAR) which revealed documentation Resident #135 received routine oxycodone as ordered on 02/22/25. Further review of the MAR revealed no documentation to support Resident #135 received oxycodone 5 mg PRN on 02/22/25. Review of the medical record for Resident #135 revealed a form titled, Controlled Drug Record which revealed documentation on 02/22/25 that Resident #135 received two tablets of oxycodone 10 mg at 10:00 A.M., 2:00 P.M., and 6:00 P.M. Further review of the form revealed documentation on 02/22/25 that Resident #135 received two tablets of oxycodone 5 mg at 10:00 A.M., 2:00 P.M., and 6:00 P.M. Interview on 06/11/25 at 3:00 P.M. with Director of Nursing (DON) confirmed Resident #135's Controlled Drug Record had documentation to support Resident #135 received the wrong doses of oxycodone 10 mg and 5 mg on 02/22/25. DON also confirmed Resident #135's February MAR had documentation to support the nurse administered one tablet, not two tablets, of oxycodone 10 mg at 10:00 A.M., 2:00 P.M., or 6:00 P.M. and no documentation to support oxycodone 5 mg tablet was administered on 02/22/25. Review of the facility policy titled, Medication Administration, revised 10/17/23, stated medications are administered in an accurate, safe, timely, and sanitary manner. The policy stated medications are administered in accordance with written orders of the attending physician. The policy also stated the staff are to record the dose, route, and time of medication administration on the Medication Administration Record. This deficiency represents non-compliance investigated under Complaint Numbers OH00163625 and OH00163227. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 26 of 31 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 06/16/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, interviews, observations, and policy review, the facility failed to follow up with dental services regarding a resident's missing dentures. This affected one (#2) of one resident reviewed for dental services. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the progress note dated 10/22/24 at 12:40 P.M. revealed Resident #2 reported missing dentures. Resident #2 was notified that dental services would be in the facility on 11/13/24. Review of the dental progress note dated 11/13/24, Resident #2 reported the facility lost his dentures and were agreed to pay for new ones. Resident #2 had impressions taken for new dentures. Review of the progress note dated 04/25/25 at 2:44 P.M. revealed Resident #2 reported to staff that he needed his dentures. Review of the progress note dated 05/16/25 at 12:47 P.M. revealed outreach attempt to dental care services to check on the status of dentures. Review of the progress note dated 06/10/25 at 2:49 P.M. revealed dental care services were contacted regarding dentures. Dentist was out on medical leave, but they could send another dentist to take new impressions for dentures for Resident #2. Observations throughout the annual revealed Resident #2 was observed without dentures. Interview on 06/09/25 at 12:51 P.M. with Resident #2 reported that the facility had lost his dentures approximately six months ago and said they would pay to get them replaced. Resident #2 stated that he had not received dentures and was not getting any assistance or follow up from the facility. Interview on 06/10/25 at 3:42 P.M. with the Administrator revealed if a resident's dentures were lost in the facility, the facility would first complete a search. The Administrator reported if the dentures were not found and the resident's insurance would not cover the cost, the facility would be responsible. The Administrator verified there was no inventory log for Resident #2. Interview on 06/10/25 at 4:30 P.M. with Social Services #329 revealed she did not follow up with dental services after Resident #2 had an appointment in November 2024 and then discharged in December 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 27 of 31 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 06/16/2025 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/11/25 at 9:04 A.M. with dental care services representative (DCSR) #501 reported Resident #2 had impressions taken for new dentures on 11/13/24, but dentures were not made because they did not receive payment. Review of the facility policy titled, Dental Services, revised 10/25/23 revealed the facility provided or obtained from an outside resource, routine and twenty-four hour emergency dental services to meet the needs of the resident and also when requested by the resident. Dentures/partials and all removable oral applications must be logged in upon admission on the personal inventory sheet, with the type of appliance and upper/lower designation. Event ID: Facility ID: 365773 If continuation sheet Page 28 of 31 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 06/16/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observations, interviews, and policy review, the facility failed to maintain infection control measures during wound care and peri care. This affected three (#3, #35, and #67) of five reviewed for infection control. The facility census was 76. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 06/15/24. Diagnoses included heart failure, dementia, delusional disorders, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 02/01/25 revealed Resident #35 had an actual impaired skin integrity related to pressure injury stage three to the coccyx with excoriation noted to peri-area. Interventions included conduct skin assessment weekly and measure area and document characteristics, observe for signs of infection, enhanced barrier precautions (EBP), and report abnormal findings to physician, obtain labs as ordered, refer to dietician as needed, and treatments as ordered. Review of the physician order dated 03/27/25 revealed Resident #35 was ordered enhanced barrier precautions related to coccyx wound. Observation on 06/12/25 at 10:48 A.M. revealed wound care was completed on Resident #35 by Licensed Practical Nurse (LPN) #304 and LPN #361. LPN #304 and LPN #361 did not apply gown for EBP precautions during wound care. Observation on 06/12/25 at 10:50 A.M. revealed LPN #304 did not perform hand hygiene after removing soiled gloves from incontinence care and then completed wound care on Resident #35. Interview on 06/12/25 at 10:59 A.M. with LPN #361 verified she did not wear a gown to assist with wound care on Resident #35. Interview on 06/12/25 at 11:01 A.M. with LPN #304 verified she did not wear a gown during wound care on Resident #35. LPN #304 also verified she did not perform hand hygiene after removing soiled gloves after incontinence care and during wound care. 2. Medical record review for Resident #03 revealed she was admitted to the facility on [DATE]. Her diagnoses included gastro-esophageal reflux disease (GERD), atrial fibrillation, borderline personality disorder, osteoarthritis of knee, congestive heart failure (CHF), anemia, edema, major depressive disorder, and obstructive sleep apnea. Review of the Minimum Data Set (MDS) assessment, dated 05/08/25, revealed Resident #03 was cognitively impaired. Resident #03 was dependent on staff for medication administration, lower body dressing, and transfers. She was independent with eating, Resident #03 required set up assistance with oral hygiene, and maximum assistance from staff with toilet use. She required moderate assistance from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 29 of 31 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 06/16/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff with showers, and personal hygiene. She was at risk for pressure ulcers. Resident #03 was marked for having zero pressure ulcers. Review of the physician orders for Resident #23 revealed no order related to enhanced barrier precautions. Review of the Treatment Administration Record for June 2025 for Resident #03 revealed no order for Enhanced Barrier Precaution. Review of the report titled, Skin and Wound Evaluation, dated 06/10/25, revealed Resident #03 had a pressure wound at a stage III that was acquired in house. Review of the facility report titled, Activity of Daily Living Task, for May 2025 revealed a reddened area was identified on 05/10/25 at the time of Resident #03's shower. Review of the wound note from the Wound Physician Assistant (WPA) #502 for Resident #03, dated 05/20/25, revealed the right buttock has a deep tissue injury persistent non blanchable deep red, maroon, or purple discoloration pressure ulcer that has received a status of not healed. The encounter measurements are 2 centimeter (cm) length x 3 cm width x 0.01 cm depth, with an area of 6 square (sq) cm and a volume of 0.6 cubic cm. The base of the wound bed has 51%-75%, bright pink, firm, granulation 1-25% slough. The diagnoses were listed as a pressure ulcer of right buttock, stage III. The plan of care was continued treatment and follow up in one to two weeks. Observation on 06/12/25 at 10:32 A.M. of Licensed Practical Nurse (LPN) #385 performed hand hygiene, however, she did don a personal protective gown for Enhanced Barrier Precautions. Observed LPN #385 clean feces from Resident #03's backside with soap and water. Observed LPN #385 remove gloves and did not perform hand hygiene. Interview with LPN #385 on 06/12/25 at 10:59 A.M. and LPN # 322 confirmed the should have utilized proper personal protective equipment related to Resident #03's enhanced barrier precautions. LPN #322 confirmed she did not wash her hands after she completed peri care. Review of the facility policy titled, Hand Hygiene, dated 05/08/25, confirmed hand hygiene should be preformed before and after contact with the resident, after contact with blood, body fluids, visible contaminated surfaces, contact with objects in the resident's room, and after removing protective equipment, after use of restroom, and before meals. Staff involved in direct resident contact must perform hand hygiene (even if gloves are used). 3. Medical record review for Resident #67 revealed she was admitted to the facility on [DATE]. Her diagnoses included acute kidney failure, cellulitis, essential primary hypertension, diabetes mellitus (DM), anemia, thrombocytopenia, and pressure ulcer of the sacral region. Review of the MDS assessment for Resident #67, dated 05/13/25, revealed she was cognitively intact. Resident #67 was dependent on staff for medication administration. Resident #67 was moderately dependent on staff for oral hygiene, toilet use, personal hygiene, and dressing. Residents require supervision for eating and bathing. Resident #67 was marked at risk for pressure ulcers and had unhealed pressure ulcers that included a stage III pressure ulcer. Review of the TAR for Resident #67, dated June 2025, revealed no order for Enhanced Barrier (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 30 of 31 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 06/16/2025 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 Precaution. Level of Harm - Minimal harm or potential for actual harm Review of the WPA #502 visit, dated 05/20/25, revealed Resident #67 was referred to WPA #502 after she was admitted to the facility with a stage III pressure ulcer on 05/13/25 revealed Resident #67 had a stage III pressure ulcer, and it has a status of not healed. Initial wound encounter was measured at 1.5 cm length x 2.0 cm width x 0.01 depth with an area pf 3 sq cm and volume of .3 cubic cm. The wound bed has 1-25% bright red, pink, firm, granulation, 51-75% slough. Residents Affected - Few Observation of wound care provided to Resident #67 on 06/12/25 at 11:26 A.M. revealed the facility failed to utilize proper personal protective equipment for enhanced barrier precautions by LPN #385 and Unit Manger (UM) #340. Interview with UM #340 confirmed they failed to don proper personal protective equipment for enhanced barrier precautions and failed to have proper notification on Resident #67's room related to enhanced barrier precaution. Review of the facility policy titled, Enhanced Barrier Precaution, dated 03/05/25, confirmed it is the intent of the facility to use Enhanced Barrier Precautions (EBP) in addition to Slandered Precautions for preventing the transmission of Centers for Disease Control targeted multi-resistant organisms (MDRO's). EBP is indicated for Residents with any of the following: infection or colonization with CDC-targeted MDRO, a wound, or an indwelling catheter medical device. Implementation included, post sign for precautions on the door or wall outside of the Resident's room that indicated type of precaution and required personal protective equipment (PPE). This deficiency represents non-compliance investigated under Complaint Number OH00163625 and OH00163227. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365773 If continuation sheet Page 31 of 31