Health inspection·September 8, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 11:15 A.M. because the staff gave her a calcium medication last night. Interview with LPN #200 on 09/02/25 at 10:15 A.M. confirmed Resident #81's appointment had to be rescheduled for 09/04/25 because there wasn't an order to hold the Calcitriol before the appointment and the resident was given medication on 09/01/25. Review of policy entitled Resident Rights dated 09/13/25 revealed the facility must protect and promote the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This deficiency represents non-compliance investigated under Complaint Number 2599291. Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 - Immediate jeopardy to resident health or safety 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff interview, Power of Attorney (POA) interview, closed medical record review, review of a facility submitted Self-Reported Incident (SRI), review of hospital records and review of the facility policy, the facility failed to ensure Resident #83, who had a diagnosis of dementia, had a previous elopement attempt from the facility, and had a Wanderguard (wearable bracelet that triggers alarms at the doors to alert when a resident attempts to exit) applied to his left ankle, did not elope from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 08/03/25 Resident #83 was able to exit the facility through an unknown facility door and staff reported they did not hear the door alarms sound. Resident #83 was subsequently found lying in the local hospital parking lot, approximately one mile from the facility, by the hospital security staff. The resident was missing for an undetermined length of time and facility staff were unaware the resident was missing until the hospital staff called to notify them that the resident was in their emergency department (ED). This affected one (#83) of three residents reviewed for elopement. The facility identified three (#83, #52 and #84) residents at risk for elopement. The facility census was 79. On 08/21/25 at 2:46 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/03/25 when Resident #83 was able to exit the facility at an unconfirmed time during the early morning hours, through locked doors, without the door alarms sounding, and without staff knowledge. The facility did not have camera surveillance to verify which door the resident exited through or how the resident was able to elope without the door alarms sounding. Licensed Practical Nurse (LPN) #326 stated she believed she last saw Resident #83 at approximately 4:00 A.M. Resident #83 traveled with his walker down a four to five lane road with posted speed limits of 40 miles per hour (MPH) that was under construction and had manhole covers protruding from the ground. The local hospital ED staff contacted the facility at approximately 5:30 A.M., after the resident was found lying in their parking lot by their security staff. Although the Immediate Jeopardy was removed on 08/04/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 08/18/25 when the facility implemented the following corrective actions: On 08/03/25 at 8:00 A.M., Resident #83 returned to the facility. Licensed Practical Nurse (LPN) #303 assessed the resident and no new injuries were identified. On 08/03/25, Unit Manager (UM) #307 reassessed Resident #83's elopement risk and identified the resident at high risk for elopement. UM #307 reviewed Resident #83's care plan to ensure the accuracy of the resident's needs and interventions. On 08/03/25, UM #307 reassessed all residents for elopement risk and updated care plans as needed. Evidence was received verifying elopement risk assessments were completed and care plans were updated, as needed, on 08/03/25. On 08/03/25, Resident #83 was placed on one-to-one (1:1) staff supervision. The resident remained on 1:1 staff supervision until 08/13/25, when he discharged to another facility with a secured memory care unit. On 08/03/25 at 8:30 A.M., the Administrator performed a Root Cause Analysis and determined staff failed to provide adequate supervision to prevent Resident #83's elopement. Staff working at the time of the incident stated they did not hear the door alarm and did not see the resident exit the facility. On 08/03/25 at 9:00 A.M., Director of Maintenance (DOM) #331 checked all current residents (#52, #83, and #84) with Wanderguards for placement and functionality, with no negative findings. Evidence was received verifying this was completed on 08/03/25. On 08/03/25, DOM #331 checked all 11 of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 - Immediate jeopardy to resident health or safety Residents Affected - Few the facility's egress doors to ensure Wanderguard door alarms were operational, with no negative findings. Evidence was received verifying this was completed on 08/03/25. On 08/03/25, DOM #331 changed the access codes for all of the facility's egress doors. Evidence was received verifying this was completed on 08/03/25. On 08/03/25, the Administrator or designee conducted an elopement drill on each of the facility's two shifts, with no negative findings. DOM #331 or designee will continue to conduct elopement drills one-time weekly on each shift for four weeks. Any concerns will be addressed immediately. Evidence was received verifying elopement drills were completed on 08/03/25 on first and second shift, 08/09/25 on first and second shift, and 08/13/25 on first and second shift. Beginning on 08/03/25 and completed by 08/04/25, the Administrator or designee provided education to all staff on the facility's elopement policy, specifically the alarm activation procedure, code search investigation procedure (missing resident procedure), and control of the egress door codes to ensure non-employees do not have access to the door codes. Evidence was received verifying education was completed by 08/04/25. Beginning on 08/03/25, DOM #331 or designee will audit all egress doors daily, Monday through Friday, to ensure functionality of the Wanderguard alarms. This will be part of daily routine maintenance. Evidence was received verifying audits were completed daily on 08/03/25, 08/04/25, 08/05/25, 08/06/25, 08/07/25, 08/08/25, 08/09/25, 08/10/25, 08/11/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25. Beginning on 08/03/25, the DON or designee will audit elopement risk assessments for all new admissions weekly for four weeks to ensure accuracy. Evidence was received verifying all new admissions and readmissions were audited for accuracy of elopement risk assessments from 08/03/25 through 08/18/25. On 08/04/25, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review Resident #83's elopement and the corrective action implemented. In attendance were the DON, the Administrator, Assistant Director of Nursing (ADON) #300, UM #324, Maintenance #325, Transportation #327, UM #307, Housekeeping Supervisor (HS) #380, Human Resources (HR) #349, DOM #331, Medical Director (MD) #800, Social Services (SS) #409, SS #388, Director of Admissions (DA) #378, Registered Nurse Minimum Data Set (RNMDS) #348, RNMDS #349, and Activities Director (AD) #355. Beginning on 08/04/25, the Interdisciplinary team (IDT) consisting of the Administrator, the DON, ADON #300, UM #324, UM #307, RNMDS #348, RNMDS #349, SS #409, SS #388, and Therapy Director (TD) #600, will audit all incidents for a significant change Monday through Friday, to ensure appropriate assessments are completed and accurate, and care plans are updated as needed. Evidence was received verifying monitoring was completed Monday through Friday on 8/04/25, 08/05/25, 08/06/25, 08/07/25, 08/08/25, 08/11/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/18/25. Review of one (#84) additional closed resident medical record and one (#52) open resident medical record, reviewed for elopement, revealed no additional concerns. Findings include: Review of a facility submitted SRI, completed on 08/08/25, revealed on 08/03/25, a local hospital contacted the facility at approximately 5:30 A.M. stating that Resident #83 was found in their parking lot. The resident was evaluated in the ED, with no injury, and returned to the facility on [DATE]. Resident #83 had a Wanderguard in place prior to the event and upon return to the facility. Facility staff were interviewed and stated they heard no door alarms sound and did not see the resident exit the facility. Review of Resident #83's closed medical record revealed an admission date of 06/04/25. Diagnoses included acute respiratory failure, paroxysmal atrial fibrillation, anemia, dementia, major depression, osteitis deformans unspecified bone, glaucoma, and insomnia. Resident #83 discharged on 08/13/25 to a facility with a secured memory care unit. Review of the elopement risk assessment, dated 07/18/25, revealed Resident #83 had an elopement risk score of 10, indicating the resident was not at risk for elopement. Resident #83 was noted to be cognitively impaired and did not wander. Review of the significant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 - Immediate jeopardy to resident health or safety Residents Affected - Few change Minimum Data Set (MDS) assessment, dated 07/23/25, revealed Resident #83 had a Brief Interview of Mental Status (BIMS) score of 01, indicating the resident was severely cognitively impaired. The MDS indicated Resident #83 had behaviors of wandering. Resident #83 had functional limitations with range of motion on both lower extremities, one side upper extremity, and utilized a walker for ambulation. Review of the plan of care revealed a focus area was initiated on 07/24/25 that Resident #83 was at risk for exit seeking due to disorientation to place, impaired safety awareness, and wandered aimlessly. Interventions included to apply Wanderguard and check placement, function and expiration date per facility protocol; approach in a slow, calm manner and redirect away from exit doors; and distract the resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, and conversations. On 08/03/25, Resident #83's care plan was revised to include 1:1 (staff supervision). Review of hospital documents, dated 08/03/25, revealed Resident #83 arrived at the ED at 5:24 A.M. to be evaluated after being found by security lying on the ground in the hospital parking lot from a fall. The resident stated that he walked very far today and was very tired and fatigued. Resident #83 stated he was discharged from a nursing home yesterday afternoon and did not want to be home alone because his wife was out of town. Nursing staff subsequently knew the resident's name and that he was a resident of a local nursing care facility. Nursing staff were able to reach the facility where the resident resided, and they stated that they were unaware the resident left the facility. Upon arrival, the resident had complaints of right-side rib and shoulder pain and denied head injury. A computed tomography (CT) scan was completed, showing acute/subacute fracture deformities of the lateral right sixth through ninth ribs. Resident #83 discharged with family back to the facility with no new orders. Review of facility document titled, Incident and Accident Investigation Form, dated 08/03/25 at 6:30 A.M., revealed that Resident #83 was at a local hospital ED. The hospital contacted the facility and reported that Resident #83 was found in the parking lot of the hospital. The facility staff were interviewed and reported providing care and assistance to the resident at approximately 4:30 A.M. Staff stated that the door alarm did not sound to alert them that the resident left out of an exit door of the facility. Resident #83's Wanderguard was in place and was checked for function, with no concerns. The hospital contacted the resident's family. Review of the facility elopement risk assessment, dated 08/03/25, revealed Resident #83 had elopement risk of 13, indicating the resident was at risk for elopement and exhibited wandering behavior. Review of a nursing progress note, dated 08/04/25 and authored by LPN #601, revealed she placed an identification (ID) band on Resident #83's left wrist. Resident #83 had a skin tear to the left elbow. The resident denied pain. Resident #83's right shoulder was seen with nonpitting edema (swelling that does not leave an indentation when pressure is applied to the area), only when moved. Resident #83 had nonpitting edema to the right elbow. Bruises were found from the right forearm to above the elbow and the resident stated he had pain when he extended his arm. Resident #83's right hip had a purple bruise over a previous surgical scar. The resident's wife was present in the room and aware. Observation on 08/20/25 at approximately 8:00 A.M. revealed the area surrounding the facility and the local hospital included four to five lane roads with posted speed limits of 40 MPH. The roads were under construction, with the pavement scraped and manhole covers protruding from the road. Interview on 08/20/25 at 2:00 P.M. with Certified Nursing Assistant (CNA) #320 revealed Resident #83 eloped during the night approximately two weeks ago. CNA #320 stated all of the staff had different stories about what happened, with one saying the door alarm was going off because of their food being delivered and another one said the resident had been checked on and there was no way he got out. CNA #320 stated Resident #83 got hurt while he was out of the facility and had a bruised rib. Interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 08/20/25 at 2:47 P.M. with the Administrator revealed Resident #83 eloped from the facility on the morning of 08/03/25. At 5:30 A.M., the local hospital called and spoke with LPN #326 and notified her that the resident was in the ED after being found in their parking lot. The Administrator stated the resident was evaluated in the ED and returned to the facility by 8:00 A.M. The Administrator stated LPN #326 last saw the resident around 4:30 A.M. A follow-up interview on 08/20/25 at 3:30 P.M. with the Administrator revealed she interviewed all of the staff who worked the night/early morning hours of 08/03/25, when Resident #83 eloped, and each denied the door alarm sounded during the hours in which the resident could have possibly eloped. The Administrator stated she educated staff on not giving the door access code to residents who smoked. The Administrator was uncertain of the exact time that the resident left the facility or how he was able to exit through the door. The Administrator stated both LPN #326 and CNA #400 stated the resident was last seen in the facility around 4:30 A.M. The Administrator reported Resident #83 discharged to a facility with a secured memory care unit on 08/13/25. Interview on 08/21/25 at 6:37 A.M. with LPN #357 revealed some residents knew the access codes to exit the facility because staff gave it to them so they could go outside and smoke. Interview on 08/21/25 at 6:49 A.M. with CNA #343 revealed she provided 1:1 staff supervision for Resident #83 after he returned to the facility from the hospital on [DATE]. CNA #343 stated the resident kept repeating that someone had picked him up in a car and dropped him off at the hospital. CNA #343 stated that when she provided care for the resident, he complained that his ribs hurt from some accident he had, and he had bruises all over his abdomen. Interview on 08/21/25 at 6:53 A.M. with LPN #346 revealed she did not work on 08/03/25. LPN #346 stated that Resident #83 was confused, alert to self, and ambulated with a walker. LPN #346 stated Resident #83 did not sleep and moved around all night. LPN #346 stated Resident #83 started looking for coffee every day at 5:00 A.M. Interview on 08/21/25 at 7:02 A.M. with CNA #402 revealed she worked on 08/03/25. CNA #402 stated Resident #83 had very bad sundowners (increased confusion and restlessness beginning in the late afternoon/early evening) and would pace around the facility. CNA #402 stated she last saw Resident #83 around 4:00 A.M. on the morning that he eloped. Interview on 08/21/25 at 7:22 A.M. with CNA #329 revealed she worked on the skilled care unit on 08/03/25 and was not assigned to provide care for Resident #83. CNA #329 denied she heard the doors alarm during her shift. CNA #329 stated that sometimes residents who were alert were given the door code to enter and exit the facility, or the residents remembered the code from watching staff enter it. Interview on 08/21/25 at 8:09 A.M. with CNA #403 revealed she did not remember anything from 08/03/25. CNA #403 denied providing care for Resident #83 on the night of 08/02/25 into the morning of 08/03/25. Interview 08/21/25 at 8:45 A.M. with Resident #83's Power of Attorney (POA) revealed she received a phone call from the police on the morning of 08/03/25, who stated the resident was being evaluated because he was found in the hospital parking lot. The POA reported Resident #83 kept stating that he was picked up by someone in a car and dropped off at the hospital. Resident #83's POA stated the Administrator told her they needed better security (at the facility). Interview on 08/21/25 at 8:57 A.M. with CNA #401 revealed she worked on 08/03/25 and was assigned to the back hall and Resident #83 resided on the front hall. CNA #401 stated that the last time she saw Resident #83 was around 1:00 A.M., as he was walking past the nurses' station. CNA #401 stated the resident was worried about his wife, who he believed had an affair with another man. CNA #401 stated that if a door alarm was sounding and she was providing care in a resident's room, she would not have heard it behind closed doors. Interview on 08/21/25 at 11:15 A.M. with CNA #400 revealed on 08/03/25, she was not assigned to provide care for Resident #83 and CNA #403 was the resident's assigned aide. CNA #400 stated she did not hear any door alarms that night but did recall seeing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #83 in the halls, confused; however, she could not recall what time she had last seen him. CNA #400 denied telling the Administrator she last saw the resident at 4:30 A.M. and further denied being interviewed by the Administrator regarding the incident at all. Interview on 08/21/25 at 11:52 A.M. with LPN #326 revealed at the beginning of her shift on 08/02/25 and into the morning hours of 08/03/25, Resident #83 was pacing in the halls. LPN #326 stated the resident had a history of exit seeking behavior. LPN #326 stated she told the Administrator that she had last seen Resident #83 sometime between 4:00 A.M. and 5:30 A.M. Further interview revealed LPN #326 did not know how the resident left the facility and denied the door alarm sounded. LPN #326 confirmed the facility was unaware the resident was missing until the hospital called at 5:30 A.M. LPN #326 stated the Administrator interviewed her regarding the elopement and she told the Administrator the resident eloped around 4:00 A.M. Interview on 08/25/25 at 3:01 P.M. with the Administrator revealed Resident #83 had previously attempted to leave the facility, which was when the Wanderguard was implemented, and the facility began exploring alternative placement for the resident. The Administrator confirmed the facility was unable to determine exactly how Resident #83 was able to exit the facility on 08/03/25 or verify the time Resident #83 eloped, but CNA #403 documented care was provided to the resident at 3:30 A.M. The Administrator stated CNA #403 had a language barrier and may not have understood what the surveyor was asking her when she stated she did not provide care for Resident #83 on the morning of 08/03/25. Upon the resident's return to the facility, he was placed on 1:1 staff supervision until a secured memory care placement could be found for him. The resident discharged to a more appropriate placement on 08/13/25. Review of the facility policy titled, Elopement Policy, dated 09/01/10, revealed it was the policy of the facility to prevent, to the extent reasonably possible, the elopement of guests/residents from the facility. This deficiency represents noncompliance investigated under Complaint Number 2586350. Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure tube feeding was provided as physician ordered. This affected one (#14) of two residents reviewed for tube feeding. The census was 79.Findings include: Medical record review for Resident #14 revealed an admission date of 04/26/25. Medical diagnoses included malignant neoplasm of part of right bronchus lung, cancer, malnutrition, depression, and history of falling. Review of the care plan dated 04/26/25 revealed Resident #14 was unable to nutritionally consume adequate food or fluids by mouth. He required a tube feeding related to malnutrition and weight loss. Intervention was to administer tube feeding as ordered. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. His functional status was partial/moderate assistance for eating, dependent for toileting, substantial/maximal assistance for bed mobility, and transfers were non-applicable. He was occasionally incontinent of bladder and frequently incontinent for bowel. He was coded for a feeding tube. Review of the admission orders dated 07/29/25 revealed Resident #14 was to be on an Enteral Feed Order one time a day Jevity 1.5 at 70 milliliters per hour (mL/hrs), at night (nocturnally) from 8:00 P.M. to 6:00 A.M. via PEG, via pump. Further review of Resident #14's medical record revealed on 07/31/25 the Jevity 1.2 was initiated for the resident, rather than the ordered Jevity 1.5. Interview with Licensed Practical Nurse (LPN) #250 on 08/28/25 at 12:56 P.M. revealed Resident #14 was admitted on [DATE] at 2:30 P.M. with orders for enteral feed for nighttime. LPN #250 stated the facility was out of the Jevity 1.5, so she asked if he could get the Jevity 1.2 until the Jevity 1.5 came in. LPN #250 confirmed he went without the Jevity 1.5 for two nights and the Jevity 1.2 was started on 07/31/25. This deficiency represents non-compliance investigated under Complaint Number 2599291. Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff and resident interviews, the facility failed to ensure medications were available from the pharmacy for administration. This affected one (#81) out of three residents reviewed for medication administration. The facility census was 79. Findings included: Review of the medical record for Resident #81 revealed the resident had a recent admission date 07/23/25. Diagnoses included chronic diastolic heart failure, hypertension, chronic kidney disease stage two, irritable bowel syndrome, non-pressure chronic ulcer right calf with fat layer exposed, anxiety disorder, and overactive bladder. Review of plan of care dated 09/22/22 revealed that Resident #81 was at risk for discomfort or adverse side effects related to receiving diuretics therapy related to congestive heart failure. Inventions included administering medication as ordered, encouraging residents to drink fluids, observe possible side effects every shift, and observing and reporting to physician dehydration or no urine. Review of plan of care dated 12/08/22 revealed that Resident #81 had risk for potential complications related to having ileostomy. Interventions included administer medication as ordered, use colostomy bag frequently, observe for diarrhea and report, and observe ostomy functioning every shift and amounts of stool passed. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #81 had Brief Interview of Mental Status (BIMS) of 15 that indicated cognitively intact. Resident #81 required setup or clean-up for meals, and dressing upper body. Resident #81 was substantial to maximum for dressing lower body and putting on and off shoes. Resident #81 was partial to moderate assistance for bathing, personal hygiene, toileting, and oral hygiene. Resident #81 used a wheelchair and ambulating with no assistance at the facility. Review of the physician order dated 08/25/25 at 4:30 P.M. revealed Resident #81 had an order for Lomotil 2.5-0.025 mg to give one tablet by mouth every four hours as needed for diarrhea. Observation on 08/25/25 at 11:01 A.M. with Resident #81 who asked for Lomotil 2.5-0.025 mg tablet from Licensed Practical Nurse (LPN) #284 during medication pass. Resident #81 told LPN #284 she asked last night with the night nurse and still had diarrhea. Interview on 08/27/25 at 11:03 A.M. with LPN #284 who stated Resident #81's Lomotil 2.5-0.025 mg tablets were not in her medication cart. LPN #284 verified that there was a physician orders active dated 08/25/25 for Lomotil for Resident #81. Interview on 08/27/25 at 11:05 A.M. with Director of Nursing (DON) stated that she expected staff to drop ship order the medication from pharmacy when ordering medication that was necessary. DON stated that the drop ship usually took four hours to receive the medication. Interview on 08/27/25 at 11:10 A.M. with Resident #81 stated she requested the Lomotil 2.5-0.025 mg tablet last night from the nurse, who stated it was not in stock. Resident #81 stated she would like Lomotil medication right now, because she was still having diarrhea. Interview on 08/27/25 at 4:07 P.M. with DON who stated that she called pharmacy about Resident #81 Lomotil 2.5-0.025 mg tablet. DON stated that Resident #81 arrived to the facility returning from the hospital on [DATE] at 5:34 P.M. DON stated she called the pharmacy who stated they needed a new prescription for Lomotil 2.5-0.025 mg tablet. DON stated the Lomotil 2.5-0.025 mg had not arrived at the at the facility yet. DON stated that the nurses were instructed for any resident who had medication that needed dropped shipped. DON stated that when medication was delivered was what the pharmacy was expecting in time frame. DON stated she had no facility policy on when facility had pharmacy delivering medication. This deficiency represents non-compliance investigated under Complaint Numbers 2597140 and 2567001. Event ID: Facility ID: 366481 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff and resident interviews, the facility failed to ensure laboratory testing was completed as physician ordered. This affected one (#14) of three residents reviewed for laboratory testing. This census was 79. Findings include: Medical record review for Resident #14 revealed an admission date of 04/26/25. Medical diagnoses included malignant neoplasm of part of right bronchus lung, cancer, malnutrition, depression, and history of falling. Review of fax from the chemotherapy physician dated 07/31/25 revealed to draw these labs on 08/01/25 and every other Friday. The labs were B-12 Folate, Iron study with ferritin, Cortisol random, Thyroid Stimulating Hormone (TSH) with reflex, free T-4, Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential, and Adrenocorticotropic Hormone Blood Test (ATCH). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. His functional status was partial/moderate assistance for eating, dependent for toileting, substantial/maximal assistance for bed mobility, and transfers were non-applicable. He was occasionally incontinent of bladder and frequently incontinent for bowel. He was coded for a feeding tube. Review of lab results dated 08/18/25 revealed the above labs were supposed to be collected, but a Prothrombin Time (PT) and International Normalized Ratio (INR) was collected. On 08/19/25 the above lab orders were supposed to be collected but all were collected except for CMP. Further review of the lab orders revealed to collect a CMP on 08/21/25. Interview with Resident #14 on 08/28/25 at 10:32 A.M. revealed he has missed a chemotherapy treatment due to the labs not being collected correctly but couldn't remember the dates. Interview with Licensed Practical Nurse (LPN) #250 on 08/28/25 at 10:45 A.M. revealed the labs were messed up on 08/18/25 when they came out to draw blood, they got a PT and INR and that was wrong. Then she ordered them to come back on 08/19/25 and she put in a STAT lab so the facility could get the resident to chemotherapy, but the lab drew everything except the CMP. She reported she had to get the CMP ordered for 08/21/25. She confirmed the labs were not collected properly. This deficiency represents non-compliance investigated under Complaint Number 2599291. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 10 of 10