Health inspection·October 6, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan for his coccyx pressure ulcer initiated on 09/07/23. MDS Nurse #107 revealed the facility had been having some difficulty with the care of wounds and the care plan was missed. 2. Review of Resident #79's medical record revealed an admission date of 01/13/23 with diagnoses including end stage renal disease, acquired absence of right leg below knee, hypertensive heart and chronic kidney disease, and generalized muscle weakness. Review of Resident #79's quarterly Minimum Data Set (MDS) assessment, dated 08/17/23, revealed the resident had intact cognition. The resident needed extensive assistance of one person for bed mobility, needed extensive of two persons for transfer, and ambulation did not occur. The assessment indicated the resident did not have a pressure ulcer injury. Review of Resident #79's progress note, dated 09/17/23 at 11:21 A.M., revealed a State Tested Nursing Assistant (STNA) was changing the guest when she saw an open wound on the coccyx and called the nurse to look at it. The nurse then asked the wound nurse to look at it and after the wound nurse looked at it a dry dressing was placed on it. Review of Resident #79's comprehensive plan of care on 10/05/23 at 11:45 A.M. revealed no care plan for her wound on her sacrum. Interview on 10/05/23 at 11:50 A.M. with the MDS Nurse #107 verified Resident #79 did not have a care plan for her sacral pressure ulcer and should. 3. Review of Resident #83's medical record revealed an admission date of 05/23/23 with diagnoses including cerebrovascular disease, failure to thrive, generalized muscle weakness, and hemiplegia and hemiparesis following unspecified cerebrovascular disease. Review of Resident #83's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/30/23, revealed the resident had impaired cognition. The resident was totally dependent of one person to assist with bed mobility, totally dependent of two persons to assist with transfers, and ambulation did not occur. The assessment indicated the resident had a non-removable dressing/devise and was at risk of developing a pressure ulcer/injury. Further review revealed she did not have a pressure ulcer/injury at that time. Review of Resident #83's progress note dated 08/14/23 and timed for 4:46 P.M. revealed a STNA came to inform the nurse that guest had an area noted to coccyx. The nurse assessed the guest 's skin and noted an area to her coccyx measuring 4 centimeters (cm) x 2 cm x 0.1 cm. Review of Resident #83's progress note dated 08/21/23 and timed for 3:41 P.M. revealed during repositioning there was noted reddened areas to bilateral heels. Review of Resident #83's significant change MDS 3.0 assessment, dated 08/29/23, revealed she was cognitively impaired. The resident needed extensive assistance of two people for bed mobility, transferring occurred only once or twice and ambulation did not occur. The assessment indicated the resident was at risk for pressure ulcers/injuries and had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar and one unstable pressure injury presenting as a deep tissue injury. Further review revealed treatments included pressure reducing devise for the bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, and application of ointments/medications other than to feet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 2 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #83's progress note dated 09/12/23 and timed 7:50 A.M revealed a STNA notified the nurse that there was blood in her depend, upon assessment the nurse noted a skin tear to Resident #83's right buttock which measured 0.1 cm x 3.0 cm x 0.6 cm. Review Resident #83's comprehensive plan of care on 10/04/23 at 10:05 A.M. revealed no care plan for Resident #83's coccyx pressure ulcer which should have been initiated on 08/17/23 and resolved on 08/24/23, no care plan for her right gluteal pressure ulcer which should have been initiated on 09/12/23 and resolved on 09/20/23 when it was noted the pressure ulcer was not on the right gluteal but the left instead, or no care plan for her her left gluteal pressure ulcer which should have been initiated on 09/20/23. Further review of her plan of care revealed Resident #83 had an actual impairment in her skin integrity related to a pressure injury which was unstageable on her bilateral heels which was initiated on 09/11/23 when the pressure ulcers were identified on 08/21/22. Interview on 10/04/23 at 3:00 P.M. with the DON verified Resident #83 did not have a care plan for her coccyx pressure ulcer identified on 08/14/23, nor a care plan for her right gluteal pressure ulcer which was really a left gluteal pressure ulcer prior to 10/04/23 and should have due to the first progress note documentation of the skin breakdown was on 09/12/23. She reported she would review it with the MDS nurse and get back with this surveyor. Interview on 10/04/23 at 3:23 P.M. with the MDS Nurse #107 verified Resident #83 did not have a care plan for her coccyx pressure ulcer initiated on 08/17/23, nor her right pressure ulcer which was really a left pressure ulcer initiated on 09/12/23. MDS Nurse #107 revealed the facility had been having some difficulty with the care of wounds. She also verified the care plan for the pressure ulcers to the bilateral heels was entered on 09/11/23 and the wounds were noted on 08/21/23. Review of the facility policy titled, Care Planning, revised 06/24/21, revealed the care plan must be specific, resident centered, individualized and unique to each resident and may include: how to manage risk factors, utilize current standards of practice and involve the family/representatives if possible. This deficiency represents an incidental finding investigated under Complaint Number OH00146429. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 3 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 Based on observation, interview, resident record review and facility policy review the facility failed to ensure a resident who had a Stage 3 (involving full-thickness skin loss potentially extending into the subcutaneous tissue layer) coccyx pressure ulcer was turned regularly and the treatment order was followed. This affected one resident (#29) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings included: Review of Resident #29's medical record revealed an admission date of 08/23/23 with diagnoses including complex lesion at T7-T10 levels of thoracic spinal cord, fusion of spine, thoracic region, abnormal posture, generalized muscle weakness, neuromuscular dysfunction of the bladder, paraplegia, and need for assistance with personal care. Review of Resident #29's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/29/23, revealed the resident had intact cognition. The resident required extensive assistance of two people for bed mobility, and transferring and ambulation did not occur. The assessment indicated the resident did not have any pressure ulcers but was at risk for developing a pressure ulcer/injury. Further review revealed skin and ulcer/injury treatment included a pressure reducing device for his bed. Review of Resident #29 plan of care, dated 08/23/23, revealed the resident was at risk for impaired skin integrity/pressure injury related to weakness, depression, impaired bed mobility, complete lesion of T7-T10, neurogenic bladder due to tumor and paraplegia. Interventions included to provide extensive assistance to reposition frequently and as needed. Review of Resident #29's wound care progress note, dated 09/07/23, revealed he was being seen for the evaluation and management of a Stage 3 pressure ulcer to his left buttock. Review of Resident #29's Skin and Wound Evaluation, dated 09/07/23, revealed he had a Stage 3 pressure ulcer to his left gluteus which measured length 3.2 centimeters (cm), width 1.5 cm, depth 0.1 cm. Review of Resident #29's physician order, dated, 09/21/23, identified the resident's wound was to be cleaned with normal saline, patted dry, apply ½ strength Dakins soaked gauze to the wound bed, and cover with a foam dressing. This was to be completed daily and as needed when soiled or dislodged. Review of Resident #29's physician order, dated 10/05/23, identified the resident's wound was to be cleaned with normal saline, patted dry, apply ½ strength Dakins soaked gauze to the wound bed, and cover with a clean dry dressing. This was to be completed daily and as needed when soiled or dislodged. Review of Resident #29's bed mobility point of care documentation, dated 09/06/23 to 10/04/23, revealed documentation to support he was assisted one time on 09/06/23, 09/09/23, 09/13/23, 09/14/23, 09/15/23, 09/18/23, 09/20/23, 09/21/23, 09/22/23, 09/23/23, 09/24/23, 09/26/23, 09/28/23, 10/02/23, and 10/03/23; two times on 09/27/23, 09/29/23, 10/01/23, and 10/04/23; three times on 09/12/23; and no documentation of turning assistance on 09/07/23, 09/08/23, 09/10/23, 09/11/23, 09/16/23, 09/17/23, 09/19/23, 09/25/23, and 09/30/23. There was no documentation to support the resident refused assistance with bed mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 4 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 - Minimal harm or potential for actual harm 1. Observation on 10/04/23 at 10:51 A.M. revealed Resident #29 lying in bed on his back wearing heel boots. Observation on 10/04/23 at 12:57 P.M. revealed Resident #29 lying in bed on his back in the same position he was in at 10:51 A.M. He was eating lunch. Residents Affected - Few Observation on 10/04/23 at 1:31 P.M. revealed Resident #29 still lying on his back. An interview at the time revealed he asked Certified Nursing Assistant (CNA) #111 to reposition him about three and one half hours ago and he still hasn't been assisted with repositioning. He reported he couldn't do it himself. Observation on 10/04/23 at 2:10 P.M. revealed Resident #29 was getting assisted with care and repositioning by CNA #111. Interview on 10/04/23 at 2:14 P.M. with MDS Nurse #107 who was sitting at the B-F nurses' station revealed she had not entered any rooms to turn or reposition residents. Interview on 10/04/23 at 2:16 P.M. with Registered Nurse (RN) #110, who was Resident #29's nurse, revealed she had helped to reposition Resident #29 at 7:00 A.M. but not since. Interview on 10/04/23 at 2:20 P.M. with CNA #111 revealed Resident #29 had not been repositioned between 7:00 A.M. and 2:10 P.M. when she was just in the room. CNA #111 reported she did not offer Resident #29 to be turned and repositioned because he doesn't like to be turned. Observation on 10/04/23 at 2:25 P.M. revealed assistant director of nursing (ADON) #109 educating CNA #111 that Resident #29 is be assisted with position changes regularly and if he refuses that is his right but the staff need to offer to turn him and document the refusal. Interview on 10/05/23 at 2:20 P.M. with the DON verified the point of care documentation for Resident #29 did not support he was turned as frequently as he should have been when he had a pressure ulcer on his coccyx and the documentation did not support he had refused assistance with bed mobility. 2. Observation on 10/05/23 at 10:00 A.M. of Resident #29's dressing change revealed the facility did not have the foam dressing needed to complete the physician order, dated 09/21/23. ADON #108 spoke with the wound Certified Nurse Practitioner (CNP) #109 who gave a new order to use a clean dry dressing as the outer dressing instead of a foam dressing. Resident #29 was informed of the process for wound care and rolled onto his left side to allow access to his coccyx where the wound was located. Observation of the outer dressing, dated 10/04/23, revealed he had clean dry dressing and not a foam gauze as was ordered prior to 10/05/23. Interview on 10/05/23 at 10:15 A.M. with ADON #108 verified the dressing, dated 10/04/23, she removed from Resident #29 was a clean dry dressing and not a foam dressing as was ordered from 09/21/23 to 10/04/23. Review of facility policy titled, Skin Management, revised 07/14/21, revealed the guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Review of the facility policy titled, Physician's Order, revised 06/24/21, revealed treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 5 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 - Minimal harm or potential for actual harm rendered to a guest/resident must be in accordance with the specific standing, written, verbal or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. This deficiency represents non-compliance investigated under Complaint Number OH00146429. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 6 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and resident record review the facility failed to ensure resident records were complete and accurate. This affected two residents (#29 and #83) of three residents reviewed for pressure ulcers. The facility census was 98. Findings included: 1. Review of Resident #29's medical record revealed an admission date of 08/23/23 with diagnoses including complex lesion at T7-T10 levels of thoracic spinal cord, fusion of spine, thoracic region, abnormal posture, generalized muscle weakness, neuromuscular dysfunction of the bladder, paraplegia, and need for assistance with personal care. Review of Resident #29's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/29/23, revealed the resident had intact cognition. The resident required extensive assistance of two people for bed mobility, and transferring and ambulation did not occur. The assessment indicated the resident did not have any pressure ulcers but was risk for developing a pressure ulcer/injury. Further review revealed skin and ulcer/injury treatment included a pressure reducing device for his bed. Review of Resident #29's progress note, dated 09/06/23 and timed for 3:14 P.M. revealed he had a new skin condition. Review of Resident #29's Skin and Wound Evaluation, dated 09/07/23, revealed he had a Stage 3 pressure ulcer to his left gluteus which measured area 3.4 centimeters (cm), length 3.2 cm, width 1.5 cm, depth 0.1 cm. The form was not complete as there was no documentation of wound bed, exudate (drainage), peri wound tissue, pain, or treatment. The form was not accurate in that the location was noted to be the left gluteus and the actual location of the pressure ulcer was the coccyx and the form also noted the wound was improving and this was the first Skin and Wound Evaluation and should have been documented as a new pressure ulcer. Review of Resident #29's Skin and Wound Evaluation, dated 09/14/23, revealed he had a Stage 3 pressure ulcer to his coccyx. The form revealed the pressure ulcer was acquired in house on 09/05/23 and the actual date of discovery was 09/06/23 based on Resident #29's progress note. The form was not complete as there was limited documentation of peri wound tissue and treatment. Review of Resident #29's Skin and Wound Evaluation, dated 09/21/23, revealed he had a Stage 3 pressure ulcer to his coccyx. The form revealed the pressure ulcer was acquired in house on 09/06/23. The form was not complete as there was limited documentation of peri wound tissue and treatment. Review of Resident #29's Skin and Wound Evaluation, dated 09/28/23, revealed he had a Stage 3 pressure ulcer to his coccyx. The form revealed the pressure ulcer was acquired in house on 09/06/23. The form was not complete as there was limited documentation of wound bed, peri wound tissue and treatment. 2. Review of Resident #83's medical record revealed an admission date of 05/23/23 with diagnoses including cerebrovascular disease, failure to thrive, generalized muscle weakness, and hemiplegia and hemiparesis following unspecified cerebrovascular disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 7 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 0842 Level of Harm - Minimal harm or potential for actual harm Review of Resident #83's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/30/23, revealed the resident had impaired cognition. The resident was totally dependent of one person to assist with bed mobility, totally dependent of two persons to assist with transfers, and ambulation did not occur. The assessment indicated the resident had a non-removable dressing/devise and was at risk of developing a pressure ulcer/injury. Further review revealed she did not have a pressure ulcer/injury at that time. Residents Affected - Few Review of Resident #83's progress note dated 09/12/23 at 7:50 A.M revealed State Tested Nurse Aide (STNA) notified the nurse that there was blood in guest depend, upon assessment the nurse noted a skin tear to Resident #83's right buttock which measured 1.0 cm x 3.0 cm x 0.6 cm. Review of Resident #83's Skin and Wound Evaluation, dated 09/12/23, revealed she had a category I flat skin tear to her right gluteus acquired in house on 09/12/23, there was no wound measurements, peri wound, pain or treatment documentation. Review of Resident #83's Skin and Wound Evaluation, dated 09/13/23, revealed she had a category I flat skin tear to her right gluteus acquired in house on 09/12/23, there was no peri wound or treatment documentation. Review of Resident #83's Skin and Wound Evaluation, dated 09/20/23, revealed she had a category I flat skin tear to her left gluteus acquired in hours on 09/12/23, there was limited documentation for wound bed, peri wound tissue and treatment. Interview on 10/04/23 at 3:50 P.M. with the Director of Nursing (DON) verified the pressure ulcer documentation regarding Resident #29 and #83 was not accurate and complete and it should have been. She verified Resident #29's pressure ulcer was not a gluteal wound, but a coccyx wound and Resident #83's pressure ulcer was not on her right gluteus, but her left gluteus. The DON verified inaccurate and incomplete documentation made it difficult to follow progression (improvement or decline) of wounds. This deficiency represents an incidental finding investigated under Complaint Number OH00146429. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 8 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review the facility failed to ensure staff wore Personal Protective Equipment (PPE) appropriately while the facility was in a COVID-19 outbreak and failed to ensure appropriate PPE was available outside of Resident #64's room who was on isolation for COVID-19. This had the potential to affect all 97 residents who did not have an active diagnosis of COVID (Resident #64 had an active diagnosis of COVID-19). The facility census was 98. Residents Affected - Many Findings included: Observation on 10/04/23 at 8:10 A.M. of signage on the main entrance door which read COVID POSITIVE Effective 09/16/23, Social distances and masking are recommended at all times. Some areas require PPE for visitations. Please see the nurse for guidance. 1. Observation on 10/04/23 at 8:11 A.M. of Certified Nursing Assistant (CNA) #103 in the dining room not wearing her N-95 mask properly. It was covering her neck and chin, and her nose and mouth were exposed. Interview on 10/04/23 at 8:25 A.M. with CNA #103 verified she was not wearing her N-95 mask properly while in the dining room at 8:11 A.M. She verified she had the mask covering her neck with her nose and mouth exposed. 2. Observation on 10/04/23 at 8:12 A.M. of Licensed Practical Nurse (LPN) #105 at the C-D Nurses Station not wearing her N-95 mask properly. The top strap of the N-95 mask was behind her neck and the bottom strap was hanging loosely in front of her neck resulting in the sides of the mask to not fitting snuggly to her face. An interview at the time with LPN #105 verified she was not wearing her N-95 mask properly due to not having the top strap over the crown of her head and the bottom strap behind her neck. 3. Observation on 10/04/23 at 8:16 A.M. of Registered Nurse (RN) #101 at a medication cart located at the B-F Nurses Station not wearing any mask at all. She verified she should be wearing mask. She reported the strap had broken and she had not donned (put on) another one yet. 4. Observation on 10/04/23 at 8:19 A.M. of CNA #102 delivering a breakfast meal to Resident #9 not wearing her mask properly. The top strap of the N-95 mask was over the crown of her head, but the bottom strap was hanging loosely in front of her neck resulting in the sides of the mask to not fitting snuggly to her face. An interview at the time with CNA #102 verified she was not wearing her N-95 mask properly due to not having the bottom strap behind her neck. She reported she had been trained in the proper wearing but forgot. 6. Observation on 10/04/23 at 8:51 A.M. of CNA #104 in Resident #64's room providing care. Signage on the door revealed the resident inside the room was in droplet isolation and staff must don (put on) gloves, a gown, and make sure eyes, nose and mouth were fully covered before entering the room. The door was cracked, and this surveyor could see CNA #104 was wearing a N-95 mask and gloves, but no gown or eye protection while providing care. Upon her exit from the room, CNA #104 did not change her mask and verified she was not wearing any gown or eye protection while in the room and did not change her N-95 mask upon exiting the room. Interview on 10/04/23 at 8:56 A.M. with LPN #106 verified CNA #104 was not wearing the appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 9 of 10 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 366457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Gahanna 5151 North Hamilton Road Columbus, OH 43230 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 - Many PPE while providing care for Resident #64 on COVID droplet isolation and should have been wearing a gown and eye protection. LPN #106 also verified CNA #104 should have changed her mask upon exiting the room. 7. Observation on 10/04/23 at 8:52 A.M., while waiting for CNA #104 to exit Resident #64's room, the isolation cart for the room was noted to not have PPE needed for entering the room. The isolation cart contained N-95 masks and gowns. There were no gloves or eye protection noted in the isolation cart. Interview on 10/04/23 at 8:56 A.M. with LPN #106 verified the isolation cart did not contain the appropriate PPE to provide care and services for a resident on droplet isolation for COVID. She verified there should have been eye protection and gloves. Interview on 10/04/23 at 9:20 A.M. with the Administrator revealed CNA #104 was sent home due to her potential exposure to COVID while providing care for a Resident #64 who was on droplet isolation for testing positive for COVID and not wearing the appropriate PPE. Review of the facility policy titled, Coronavirus (COVID 19), last revised 07/23/23, revealed appropriate measure will be utilized for the prevention and control of the Coronavirus (COVID 19). The policy revealed the facility will follow the Core Principles of COVID-19 Infection Prevention and Control (IPC) including face covering or mask (covering mouth and nose) in accordance with the Center for Disease Control guidance and appropriate staff use of PPE. Further review revealed all recommended COVID-19 PPE should be worn during care pf residents under observation or in Transmission Based Precautions, which include use of a NIOSH approved N95 or higher level respirator, eye protection (i.e. goggles or a face shield that coves the front and sides of the face), gloves, and gown. This deficiency represents an incidental finding investigated under Complaint Number OH00146429. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366457 If continuation sheet Page 10 of 10