Health inspection·December 29, 2025

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident's health has improved sufficiently so the residents no longer need the services provided by the facility. c. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. f. An immediate transfer or discharge is required by the residents' urgent medical needs. g. The resident is transferred for other than medical reasons. h. The resident has not resided in the facility for thirty (30) days; and/or i. The facility ceases operating. 2. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. The name, address, and telephone number of the state long-term care ombudsman. e. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. 3. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility. -On 12/15/25, a Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Director of Nursing, Medical Director #275 and SSD #180 was held to review the discharge policy and procedure. No changes were made to the discharge policy and procedure at this time. -On 12/17/25, the Facility Administrator was in-serviced by [NAME] President of Operations #375 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge. -On 12/17/25, a full Intradisciplinary Team (IDT) meeting was held which included the Administrator, DON, SSD #180, Business Office Manager (BOM) #152, Assistant Director of Nursing (ADON) #166, and Activity Director #128 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge that addressed the following: 1. Except as specified below, a resident, and/or his or her representative will be given thirty (30)-day advance notice of an impending transfer or discharge from our facility: a. The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. c. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. f. An immediate transfer or discharge is required by the residents' urgent medical needs. g. The resident is transferred for other than medical reasons. h. The resident has not resided in the facility for thirty (30) days; and/or i. The facility ceases operating. 2. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. The name, address, and telephone number of the state long-term care ombudsman. e. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. 3. The facility will not transfer or discharge the resident while an appeal for discharge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 2 of 9 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 12/29/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility. -On 12/19/25, A full house education was done by the Administrator and DON regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge. -Pending discharges will be discussed in the Stand-up Meeting daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday, with the IDT to ensure safe discharge plans and teaching or other needs. The IDT includes the following: Administrator, DON, ADON #166, BOM #152, SSD #180, and Activity Director #128. In the absence of one of these team members the other team members will act on their behalf. -The Administrator, DON, or SSD #180 will notify Medical Director #275 of any pending discharge plans daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday. -Pending discharge plans will be reviewed by the Administrator and/or designee and Director of Nursing and/or designee in Stand-up Meeting at least 3 times weekly for 6 weeks to ensure safe discharge plans have been made. Although the Immediate Jeopardy was removed on 12/19/25, the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review for Resident #79 revealed the resident was admitted to the facility in 05/2003 and had diagnoses which included type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term use of insulin. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, revealed the resident was cognitively intact. Review of the care plan, initiated on 06/05/19 and cancelled on 12/09/25, revealed Resident #79 was at risk for impaired visual function related to history of cataracts, history of glaucoma, and diabetes mellitus with history of diabetic retinopathy and cataracts. Interventions included refer to ophthalmologist/optometrist as needed. Review of the care plan, initiated on 10/26/25 and cancelled on 12/09/25, revealed Resident #79 had a functional ability deficit and required assistance with self-care/mobility related to celiac disease, diabetes mellitus type one retinopathy, hypomagnesemia, Vitamin D deficiency, hypokalemia, and anemia. Interventions included staff to assist with completion of Activities of Daily Living (ADLs) daily. Review of the care plan, initiated on 06/05/19 and cancelled on 12/09/25, revealed Resident #79 was at risk for fluctuation in blood sugar levels related to diabetes mellitus. Required daily insulin, hypoglycemic unaware, and non-compliance with diabetic diet. Able to draw up own insulin into syringe. Had a history of requiring supervision to draw insulin up into syringe to assure correct dose is drawn up and required teaching to alternate sites of insulin injections. Required oversight with diabetic regimen due to history of non-compliance and knowledge deficits. Chooses to perform his own accu-checks at times. Prefers nursing staff to administer his insulin to him at times. Requires supervision with insulin regimen. Interventions included observe for signs and symptoms of hyperglycemia and hypoglycemia, provide supervision when performing own accu-checks and educate as needed when not performing accu-checks per facility standards, supervise when drawing up own insulin into syringe to ensure correct dose of insulin is drawn up into syringe, and supervise when giving own insulin injections and ensure that guest is performing insulin injection correctly and is alternating sites of injections. Review of the care plan, initiated on 03/06/20 and cancelled on 12/09/25, revealed Resident #79 required 24-hour care/Long Term Care (LTC) placement at this time. Resident has verbalized acceptance of plans to remain in the facility. Interventions included assessing discharge plans on admission and review quarterly. Review of all additional care plans for Resident #79 revealed no care plans for discharge planning/discharge were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 3 of 9 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 12/29/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in place at the time the resident was discharged on 12/08/25. Review of the physician's orders, revised on 09/28/25 and ending on 12/10/25, revealed resident may draw up his own insulin and may keep glucometer at bedside to monitor blood sugars. No physician orders to self-administer insulin or other medications were present. Review of the Optometry Order Form, dated 06/30/25, revealed an order to refer to local Optometrist for neovascularization of disc, left eye (a process that can occur in our body when new blood vessels grow which may leak and cause vision loss). No additional optometry appointments or visit notes were available for review. Review of the neurocognitive assessment and testing results, dated 07/09/25, revealed Resident #79 had resided at the facility for the previous 22 years due to a long history of medical problems. The resident had a high school education and had never worked or had a job due to medical problems and had been generally supported by his parents most of his life. The resident is single and lives with a roommate at the extended care nursing facility. Both parents are deceased . He does have friends at the facility. The results of the current evaluation on Resident #79 reveal him to be a gentleman whose innate intellectual levels of function were judged to be generally within the average range. His academic levels are well within the normal range as well. He does seem to do better somewhat with nonverbal processing of information than verbal processing of information; however, his visual memory appears to be somewhat less than his verbal memory. His comprehension of ordinary affairs as well as adaptive functioning as indicated by the individual at his care facility would indicate that he has some difficulty with executive functioning and general socialization and interaction with others. While no significant psychopathology was indicated he does appear to be somewhat immature for his age and past traumatic issues were indicated and guardedness. I believe that Resident #79 has developed what appears to be some learned helplessness in terms of doing things. Clearly, intellectually he functions within the average range. Memory functions are somewhat variable, but his adaptive skills are below expectations. Review of the facility CHMI -Social Service-Re-eval - V3 assessment, dated 07/15/25, revealed Resident #79 was a long-term guest with no plans for discharge. Resident #79 has been a long-term guest for the last 22 years. Review of the facility Care Plan Conference Summary V2, dated 08/21/25, revealed topics discussed included discharge potential. The Interdisciplinary Team (IDT) held a care conference with resident to discuss plan of care. Resident is a long-term resident with no plans for discharge. Resident is happy with the care at the facility. Review of the facility CHMI-Social Service - Re-eval - V3 assessment, dated 09/07/25, revealed the resident was a long-term guest with no plans for discharge. Review of the physician progress note, dated 09/15/25, revealed Resident #79 was seen for follow-up of his diabetes mellitus, celiac disease with associated deficiencies, allergic rhinitis, and anemia. The resident is now using a continuous glucose monitor. Resident notes last sensor only lasted 14 days. Told him that the typical lifespan of them is 14 days and they have to be changed every two weeks. He voiced understanding of this. Assessment/plan: Diabetes Mellitus type 1. The resident is on 35 units of Lantus (a long-acting insulin) and 5 units of Novolog (a fast-acting insulin) three times a day. I am going to go ahead and modify the Novolog to six units three times a day. Small changes in insulin have resulted in large changes in blood sugar. Continue his sliding scale (insulin administration based on blood sugar results). Review of the facility Care Plan Conference Summary V2, dated 11/18/25, revealed topics discussed included discharge potential and insurance/financials. Care plan reviewed, code status discussed, no change indicated at this time. Review of the facility progress notes, dated 07/10/25 through 12/07/25, revealed no evidence of discharge planning, notice of intent to discharge, or need for discharge from the facility for Resident #79. No evidence of diabetic teaching was documented. No evidence of attempts to obtain income or alternative housing was documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 4 of 9 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 12/29/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility progress note, dated 12/08/25 and timed 2:09 P.M., revealed Resident #79 was discharged to the community with meds per Medical Director #275. Review of the facility Discharge Plan of Care, dated 12/08/25, revealed Resident #79 was being discharged to a homeless shelter/housing program. Social support in community/family assistance were listed as a Pastor and a friend. A follow-up appointment had been scheduled with a physician on 12/10/25 at 9:00 A.M. Nutritional needs included a carbohydrate-controlled diet. Discharge medication orders included a FreeStyle Libre 3 Reader Device (Continuous Glucose System Receiver), FreeStyle Libre 3 Sensor Miscellaneous (Continuous Glucose System Sensor), Novolog Injection Solution 100 unit/milliliter (ml), Glucose 15 Gel 40 percent, Glucagon (rDNA) Kit 1 milligram (mg), Lantus Subcutaneous Solution 100 unit/ml, Ferrous Sulfate 325 mg, MagOx 400 Oral tablet, Calcium-D Tablet 600-400 mg-unit, potassium cl ER 20 milliequivalent (mEq), Tylenol tablet 325 mg, loratadine 10 mg tablet, daily vite tablet, Vitamin C oral tablet, and Vitamin D3 oral tablet 1.25 mg. The number of medications sent with the resident had not been filled in. Review of the physician progress note, dated 12/08/25, revealed Resident #79 was seen for discharge. The resident had been residing at the facility for 22 years. At the time of his admission, he was found to be homeless, living at the local rest stop with out-of-control diabetes, weighing about 90 pounds, and suffering from severe protein-calorie malnutrition. The resident also has celiac disease with associated multiple deficiencies. He is unfortunately somewhat non-compliant with his gluten-free diet. The resident's third-party payor had unfortunately dictated they will not cover his care at this service and other alternatives including assisted living have apparently not been covered either by the insurance company and they are forcing a discharge. We have had multiple conversations with them about the residents' unique set of circumstances including his diabetes with very brittle control and his hypoglycemia unawareness where unfortunately the first symptom of hypoglycemia is typically unconsciousness. He is going to the homeless shelter where he will be supervised initially at least. He has primary care follow-up scheduled with a community physician. The resident himself feels well today but is somewhat overwhelmed with the discharge process as he has quite a lot of belongings which have been accumulated in the 22 years here in the facility. He is up and ambulatory. He has been able to check his sugars here using a Libre 3 device and has been taught to manage his sliding scale. Assessment/plan - diabetes mellitus with labile control. History of Diabetic Ketoacidosis 22 years ago but never since. Will be discharging to a homeless shelter as noted above. Has a new book for his sliding scale. Will be seeing a primary care provider in the community in two days' time and I will speak with that provider personally and give him a history. Social - as noted above, social situation is tenuous but unfortunately insurance has given us no other choice in this matter. Will try to arrange for follow-up as we can obtain, but I do believe the resident will likely be at risk for rehospitalization. This has been relayed to the third-party payor. Electronically signed by Medical Director #275 on 12/08/25 at 9:35 P.M. Interview on 12/11/25 at 9:30 A.M. with SSD #180 confirmed the employee had just started the position of Social Service Director three weeks ago. SSD #180 stated she had been employed as a Certified Nursing Assistant (CNA) in the facility prior to taking the position as SSD and was receiving education and training from the Administrator. Interview on 12/11/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #179 confirmed the employee had worked in the facility on 12/07/25 and was not aware of an upcoming discharge date or location for Resident #79. LPN #179 stated Resident #79 seemed autistic and had been left at a truck stop 22 years prior weighing around 90 pounds. LPN #179 stated she had not worked in the facility on 12/08/25 but confirmed Resident #79 was discharged to a homeless shelter on that day. Interview on 12/11/25 at 11:10 A.M. with Business Office Manager (BOM) #152 confirmed the facility changed ownership in 07/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 5 of 9 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 12/29/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few BOM #152 confirmed they were sent a request for records by Resident #79's insurance company in 10/2025 and had not been getting paid for the residents stay in the facility for quite some time. BOM #152 confirmed the records were sent as requested and a denial notice was received. BOM #152 confirmed the facility was unable to find alternate placement for Resident #79 other than the homeless shelter. Interview on 12/11/25 at 11:28 A.M. with the Director of Nursing (DON) confirmed the employee had worked at the facility for six years and a new company had taken over in 07/2025. The DON confirmed Resident #79 was discharged to a homeless shelter located in the same county as the facility on 12/08/25. The DON confirmed the resident did not have a Guardian or Power of Attorney (POA) and was his own responsible person. The DON confirmed there had been discussion during a recent care conference about the resident being discharged but she was unsure where the process was at following the care conference. The DON confirmed the day after the care conference the facility received a call from the quality control department from the insurance company stating a complaint had been voiced by Resident #79's case manager regarding the facility not assisting with the discharge process. The DON confirmed she was not aware when leaving the facility on Friday 12/05/25 the resident would be discharged on Monday 12/08/25. Observation inside Homeless Shelter #500 on 12/11/25 at 1:30 P.M. revealed Resident #79 was sitting at a table in the common area watching television. Interview with the resident at the time of the observation confirmed facility staff had entered his room on the morning of 12/08/25 and told him to pack up his belongings. The resident denied knowledge he was being taken to the homeless shelter. Interview on 12/11/25 at 1:33 P.M. with Homeless Shelter House Manager (HSHM) #305 confirmed the homeless shelter was only permitted to allow people to stay for a maximum of 90 days. HSHM #305 confirmed people staying at the shelter were only permitted to have a small tote full of personal items and toiletries due to limited space. HSHM #305 confirmed Resident #79 came to the shelter with medications but without needles to inject his insulin. HSHM #305 confirmed facility staff brought needles to Resident #79 a couple days later. HSHM #305 confirmed the facility had told the shelter staff Resident #79 needed to come stay there or he would be out on the street. Interview on 12/11/25 at 1:59 P.M. with the Administrator and SSD #180 confirmed Resident #79's stay at the facility was denied payment by his insurance due to him not requiring the level of care provided by the facility. They confirmed the facility had not been getting paid for his stay since 03/2022. They confirmed he did not qualify for group homes due to not having the correct diagnoses in place. They confirmed referrals had been sent to other Skilled Nursing Facilities all with denials. They confirmed Homeless Shelter #500 was discovered by SSD #180 and the shelter had community readiness programs in place. They confirmed on 12/08/25 Resident #79 was discharged to Homeless Shelter #500. They confirmed no discharge notice had been provided to Resident #79 as he was agreeable to go. They confirmed no discharge notice had been made to the Ombudsman as of the present date and time. Interview on 12/11/25 at 2:35 P.M. with Resident #74 confirmed he was the roommate of Resident #79 prior to the resident being discharged . Resident #74 confirmed an employee who had just gotten promoted came in and told Resident #79 they had found him a place to go and made it sound like an assisted living apartment where he could cook for himself and have his own place. Resident #74 confirmed Resident #79 got some of his clothes and stuff and they took him away. Resident #74 stated I found out the next day Resident #79 was dropped off at some homeless shelter. I can't believe they would do someone dirty like that. Telephone interview on 12/11/25 at 2:59 P.M. with Resident Representative #509 confirmed she was a former employee of the facility and a friend of Resident #79. Resident Representative #509 confirmed that a current employee of the facility had messaged her and informed her Resident #79 was sent to live at the homeless shelter. Resident Representative #509 confirmed she was told Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 6 of 9 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 12/29/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #79 had not been informed he was being discharged . Telephone interview on 12/15/25 at 9:14 A.M. with Resident Representative #400 confirmed she had been employed at the facility until around 08/2025 and was friends with Resident #79 as she had worked at the facility for 16 years. Resident Representative #400 confirmed Resident #79 was testing his own blood sugar, but nurses were administering his insulin. Resident Representative #400 confirmed Resident #79 was managing his own insulin at the homeless shelter but did not have the cognitive ability to make judgements regarding changing dosages based on his insulin levels. Resident Representative #400 confirmed she had to purchase insulin pen needles and insulin syringes for Resident #79 on 12/13/25 as the facility had not provided him with enough. Resident Representative #400 confirmed the facility had made a follow-up appointment for Resident #79 with a doctor to take place on 12/10/25 but did not arrange for transportation and the resident missed the appointment. Resident Representative #400 confirmed the resident called and messaged her frequently and had never mentioned being discharged until 12/08/25. Resident Representative #400 confirmed Resident #79 did not have a Driver's License, State Identification card, copy of his Social Security card, copy of his Birth Certificate, or income to assist himself in obtaining a job, income, or housing. Telephone interview on 12/15/25 at 9:30 A.M. with Insurance Employee #410 confirmed the employee was unaware Resident #79 had been discharged by the facility to a homeless shelter. Insurance Employee #410 confirmed Resident #79's insurance had stopped paying for the residents stay at the facility a couple years prior due to the resident not requiring the level of care provided at the facility. Insurance Employee #410 confirmed facility staff had told the insurance company they would just keep the resident there and deal with it. Interview on 12/15/25 at 1:50 P.M. with Medical Director #275 confirmed he had known Resident #79 since the resident was first admitted to the facility. Medical Director #275 confirmed Resident #79 had fallen through the cracks. Medical Director #275 confirmed Resident #79 had no Developmental Disability (DD) diagnosis but was likely autistic. Medical Director #275 confirmed he was aware of the need for the resident to be discharged from the facility at some point but the discharge to the homeless shelter was sudden and he was notified only about an hour before the discharge. Medical Director #275 confirmed Resident #79 was not safe to use syringes due to impaired vision and insulin pens with needles were better to administer his insulin as he had some diabetic retinopathy. Telephone interview on 12/15/25 at 2:31 P.M. with Insurance Company Case Worker #425 confirmed she had spoken with a social service employee at the facility about the goal of discharge for Resident #79 as the residents' stay was not being covered due to not meeting the criteria for placement at a Skilled Nursing Facility. Insurance Company Case Worker #425 confirmed she had talked with facility staff about the need to assist with finding some sort of income so Resident #79 could get alternate placement. Insurance Company Case Worker #425 confirmed the previous facility staff/social worker had stated Resident #79 could just remain in the facility and they would work towards getting income. Insurance Company Case Worker #425 confirmed she was not notified until 12/10/25 that Resident #79 had been discharged to a homeless shelter on 12/08/25. Telephone interview on 12/16/25 at 9:05 A.M. with Resident Representative #450 confirmed she had been the previous social worker at the facility and was employed there until 09/12/25. Resident Representative #450 confirmed she had worked at the facility for just short of nine years and there had been no plans for Resident #79 to be discharged as of her ending employment with the facility on 09/12/25. Resident Representative #450 confirmed Resident #79 was immature mentally. Resident Representative #450 confirmed there was no discharge planning documentation as of her leaving employment on 09/12/25 due to the facility agreeing to allow the resident to remain there. Resident Representative #450 confirmed Resident #79 had reached out to her stating he just wanted to go home. Interview on 12/16/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365994 If continuation sheet Page 7 of 9 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 12/29/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at 10:12 A.M. with the Administrator and DON confirmed the Executive Director of Homeless Shelter #500 had posted a list on Facebook of all the services the shelter offered. They confirmed they did not assist with setting up transportation to the follow-up appointment for Resident #79 as the Executive Director of Homeless Shelter #500 had stated he would assist in doing so. They confirmed there was no documentation of self-administration of insulin or other medications in the resident's medical record since 12/04/24. They confirmed there was no additional documentation of discharge planning or diabetic teaching in the resident's medical record since 07/2025. Telephone interview on 12/16/25 at 10:40 A.M. with Executive Director #360 (Homeless Shelter #500 employee) confirmed he had told staff at the facility this would not be a good program for Resident #79 as the resident did not have any recent work skills or references, had no income, and had no life skills. Executive Director #360 confirmed he told the facility as a last resort they would be happy to help. Executive Director #360 confirmed after 90 days the resident would be discharged out of the homeless shelter and there were no good housing options for him. Executive Director #360 confirmed medical care and treatment were not provided by himself or House Manager #305 and they were the only two employees of the shelter. Executive Director #360 confirmed Resident #79 seemed to have the mentality of a child and appeared to be agoraphobic (fearing or avoiding places or situations which might cause panic) as he almost always remained in his dorm on his bed. Interview on 12/16/25 at 11:51 A.M. with Ombudsman #250 during her visit to the facility revealed a complaint regarding an inappropriate discharge had been called into the Ombudsman's office for Resident #79. Ombudsman #250 confirmed she had visited Resident #79 at Homeless Shelter #500 and he had stated he was unaware of discharge plans prior to 12/08/25 and wanted to return to the facility. Ombudsman #250 confirmed she had not been notified by the facility of the plan to discharge the resident before or after his discharge. Ombudsman #250 confirmed she was filing an appeal regarding the resident's inappropriate discharge. Interview with LPN #179 on 12/16/25 at 2:31 P.M. confirmed Resident #79 was able to draw up his own insulin but had problems with his eyesight and did not do well with insulin vials and insulin syringes. Telephone interview on 12/16/25 at 3:52 P.M. with Insurance Employee #472 confirmed neurocognitive testing had been completed for Resident #79 prior to his discharge which showed the resident had developed learned helplessness while residing in the facility. Insurance Employee [TRUNCATED] Event ID: Facility ID: 365994 If continuation sheet Page 8 of 9 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 12/29/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on closed record review and staff interviews, the facility failed to provide notice of discharge timely and appropriately. This affected one resident (#79) out of the four residents reviewed for discharge. The facility census was 74.Findings include:Closed record review for Resident #79 revealed the resident was admitted to the facility in 05/2003 and had diagnoses which included type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term use of insulin.Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, revealed the resident was cognitively intact.Further record review for Resident #79 revealed no discharge notice had been provided to the resident or Ombudsman prior to the resident being discharged from the facility on 12/08/25.Interview on 12/11/25 at 1:59 P.M. with the Administrator and Social Service Director #180 confirmed no discharge notice had been provided to Resident #79 as he was agreeable to go. They confirmed no discharge notice had been made to the Ombudsman as of the present date and time.This deficiency represents non-compliance identified during the investigation of Complaint 2690578 and 2688635. Event ID: Facility ID: 365994 If continuation sheet Page 9 of 9