Health inspection·June 9, 2022

F 0569 representative was provided with a spend-down notification on 03/21/22, with no other action taken. Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident #43's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $3,663.18 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. Residents Affected - Some 5. Review of Resident #50's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $5,309.03 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 6. Review of Resident #59's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $5,967.09 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 7. Review of Resident #64's financial records revealed he utilized Medicaid as his insurance source. According to his current account statement, the resident had $5,925.79 available in his trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 8. Review of Resident #68's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $3,528.97 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 9. Review of Resident #71's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $5,257.38 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 10. Review of Resident #74's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $6,098.77 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 11. Review of Resident #75 financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $9,210.38 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 12. Review of Resident #79's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $4,437.51 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. Interview with Business Office Manager (BOM) #204 on 06/07/22 at 12:05 P.M. verified Residents #28, #35, #40, #43, #50, #59, #64, #68, #71, #74, #75 and #79 have a balance over the allowable $2,000 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 2 of 7 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some limit for Medicaid Personal Trust Accounts. BOM #204 stated all twelve residents were issued a spend-down notification on 03/21/22. BOM #204 verified the facility has taken no other actions since then in attempt to decrease these fund accounts. Review of the facility's policy titled Resident Trust Fund Management, dated October 2019, revealed the facility will maintain the management of resident trust fund accounts in each campus to ensure compliance with state and federal guidelines. The campus will notify resident in writing who receives Medicaid benefits when the balance of the account was $200 less than the maximum amount allowed to be eligible for Medicaid. Review of the facility's undated policy titled Medicaid Fund Surplus revealed the definition of a surplus of funds was when there was an amount of cash over the resource limit for an active Medicaid recipient. Having a surplus at the time of Medicaid application or recertification can cause eligibility to be denied. To ensure the funds are appropriately spent down below the resource limit, follow the below process: funds should be spent on the needs of the resident. Clothes, toiletries, electronics, etc. Or a pre-paid burial plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 3 of 7 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update a resident's Pre-admission Screening and Resident Review (PASARR) when a significant change occurred or was discovered. This affected two (Resident #4 and #33) of two residents reviewed for PASARR. The facility census was 86. Findings include: 1. Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE]. His diagnoses included dementia, major depressive disorder, psychosis, delusional disorder, anxiety disorder, and unspecified behavioral syndromes associated with physiological disturbances and physical factors. Review of his Minimum Data Set (MDS) 3.0 assessment, dated 05/22/22, revealed Resident #4 had a mild cognitive impairment. Review of Resident #4's PASARR screening document, dated 09/13/17, revealed under section C, Medical Diagnosis, it indicated Resident #4 did not have a diagnosis of dementia. Also under section C, the only mental health diagnosis indicated was mood disorder. Review of Resident #4's face sheet and diagnosis list revealed the following diagnoses and dates on onset, which should have been indicated on the PASARR screening document: dementia (12/28/21), major depressive disorder (09/18/17), psychosis (09/17/17), delusional disorder (12/16/21), and anxiety disorder (12/20/18). Interview with Social Services Staff (SSS) #242 on 06/08/22 at 8:27 A.M. confirmed Resident #4's PASARR was not accurate and up to date. SSS #242 confirmed when there was a significant change in a resident's diagnosis or if she finds a mistake in the PASARR, she was to correct it, and re-submit it to the state mental health agency. 2. Review of Resident #33's medical record revealed Resident #33 was admitted to the facility on [DATE]. Her diagnoses included dementia, psychosis due to a substance or known physiological condition, and anxiety disorder. Review of her MDS 3.0 assessment, dated 04/06/22, revealed Resident #33 had a severe cognitive impairment. Review of Resident #33's PASARR screening document, dated 02/16/22, revealed under section C, Medical Diagnosis, it indicated Resident #33 did not have any mental health diagnoses. Review of Resident #33's face sheet and diagnosis list revealed the following diagnoses and dates of onset, which should have been indicated on the PASARR screening document: unspecified psychosis due to a substance or known physiological condition (03/14/22) and anxiety disorder (03/08/22). Review of Resident #33 PASARR screening document, dated 06/08/22, revealed under section C, Medical Diagnosis, it indicated Resident #33 only had mood disorder. Interview with Social Services Staff (SSS) #242 on 06/08/22 at 8:27 A.M. confirmed Resident #33's PASARR was not accurate and up to date. SSS #242 confirmed when there was a significant change in a resident's diagnosis or if she finds a mistake in the PASARR, she was to correct it, and re-submit it to the state mental health agency. She confirmed she updated Resident #33's PASARR this morning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 4 of 7 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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 0644 Level of Harm - Minimal harm or potential for actual harm (06/08/22) due to seeing the mistakes that were on it. SSS #242 also confirmed that even with the update completed on 06/08/22, it still did not indicate all Resident #33's mental health diagnoses. SSS #242 stated would redo the PASARR again. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 5 of 7 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to ensure pressure relieving devices to prevent new or worsening pressure ulcers were in place as ordered by the physician. This affected one (Resident #11) of five residents reviewed for pressure ulcers. This facility identified nine residents residing in the facility who had pressure ulcers. The facility census was 86. Residents Affected - Few Findings include: Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of the left heel, hypertension, restless leg syndrome, hemiplegia and hemiparalysis affecting the left side, and cerebral infarction. Review of the significant change Minimum Data Set (MDS) assessment, dated 03/09/22, revealed Resident #11 had severely impaired cognition. Resident #11 required extensive assistance from one staff member for bed mobility and transfers. Resident #11 had one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) which was present upon admission to the facility. Review of the physician's order, dated 11/15/21, revealed Resident #11 had an order for bilateral heel protectors to be on at all times, may remove for bathing. Review of Resident #11's Treatment Administration Record (TAR), dated 06/01/22 through 06/07/22, revealed documentation that heel protectors were on as ordered on day and night shift. Review of the TAR, dated 06/08/22, revealed documentation heel protectors were on as ordered on day shift. Review of the progress notes, dated 01/01/22 through 06/07/22, revealed no documentation of refusal to wear heel protectors by Resident #11. Observation on 06/06/22 at 10:18 A.M. revealed Resident #11 was sitting up in the wheelchair beside the bed in the resident's room. No heel protectors were observed to be worn by Resident #11 on either foot. Observations on 06/06/22 at 2:35 P.M., on 06/07/22 at 11:15 A.M., on 06/07/22 at 3:06 P.M., and on 06/08/22 at 10:05 A.M. revealed Resident #11 was sitting up in the wheelchair beside the bed in the resident's room. No heel protectors were observed to be worn by Resident #11 on either foot. Observation and interview with Licensed Practical Nurse (LPN) #217 on 06/08/22 at 10:10 A.M. verified Resident #11 did not have heel protectors on either foot and there were no heel protectors visible in the resident's room. This deficiency substantiates Master Complaint Number OH00132840, and Complaint Numbers OH00131931, and OH00131415. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 6 of 7 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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 observation, staff interview, and record review, the facility failed to ensure fall prevention measures were in place as ordered by the physician. This affected one (Resident #59) of one resident reviewed for falls. The facility identified 14 residents who had falls in the past 90 days. The facility census was 86. Findings include: Record review for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of the right femur, age related osteoporosis, hypertension, need for assistance with personal care, and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/25/22, revealed Resident #59 had severely impaired cognition. Resident #59 required extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the physician's order, dated 03/22/22, revealed an order for Dycem (non-slip device) to Resident #59's wheelchair. Review of the facility's fall investigation, dated 03/24/22, revealed Resident #59 was observed by staff to have fallen on the floor. Resident #59 was transferred to the hospital and diagnosed as having a fractured right femur. The new intervention implemented by the facility to prevent future falls was Dycem to Resident #59's wheelchair. Observation on 06/09/22 at 9:30 A.M. revealed Resident #11 was observed to be sitting in her wheelchair in her room. Registered Nurse (RN) #214 and State Tested Nursing Assistant (STNA) #124 attempted to locate the Dycem on Resident #59's wheelchair and were unable. RN #214 and STNA #124 then wheeled Resident #59 to the shower room where they utilized the mechanical lift to raise the resident up. No Dycem was observed to be in the resident's wheelchair on top of or below the wheelchair cushion. Interview with RN #214 and STNA #124 on 06/09/22 at 9:35 A.M. verified there was no Dycem located in the wheelchair of Resident #59. STNA #124 stated the Dycem had likely not been replaced by staff after the wheelchair was cleaned on night shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 7 of 7