Inspection·November 17, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few food had been runny. ST #270 confirmed during the lunches on 11/14/22 and 11/15/22, Resident #23 had liquid like food running down her chin. She revealed Resident #23 had shakiness in her arms due to Parkinson's disease. ST #270 revealed she was aware of the order and recommendation to assist Resident #23 with eating due to difficulty with getting the food into Resident #23's mouth. ST #270 revealed about a week ago staff informed her of Resident #23 having some difficulty with the dysphagia mechanical diet and was coughing and pocketing food so she recommended switching Resident #23 to a pureed diet. Interview on 11/16/22 at 3:44 P.M. with Diet Tech #273 revealed if food was dripping off the spoon and running down Resident #23's face, then the pureed food was too thin. Observation on 11/17/22 at 7:50 A.M. revealed staff was placing a clothing protector on Resident #23 for breakfast. Resident #23 was sitting in the common space near the nurses station. The breakfast tray was not passed to Resident #23 until 9:06 A.M. Resident #23 continued to wear the clothing protector while waiting for her food. Interview on 11/17/22 at 9:00 A.M. with Resident #23 revealed she thought she was getting food soon when the staff put the clothing protector on, but revealed she had to wait forever for her food to come. Interview on 11/17/22 at 9:12 A.M. with State Tested Nurse Aide (STNA) #240 confirmed Resident #23's dignity was not maintained when Resident #23 had to sit for over an hour wearing a clothing protector while waiting for her food. Based on medical record review, observation, and staff interview, the facility failed to ensure residents were treated in a dignified manner. This affected two (#13 and #23) out of three residents reviewed for dignity. The facility census was 66. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 07/30/20. Diagnoses included generalized idiopathic epilepsy, dementia without behavioral disturbance, hemiplegia and hemiparesis, major depressive disorder, and malignant neoplasm of brain. Review of the quarterly Minimum Data Assessment (MDS) assessment, dated 08/19/22, revealed Resident #13 had severely impaired cognition. Resident #13 required extensive assistance of one staff for eating. Observation on 11/14/22 at 12:08 P.M. revealed Nursing Assistant (NA) #271 was standing in the dining room next to Resident #13, who was seated at the table, assisting the resident with eating green beans. Continued observation from 12:08 P.M. to 12:13 P.M. revealed NA #271 continued to stand next to Resident #13 and assist her with eating. Interview on 11/14/22 at 12:13 P.M., with NA #271 confirmed she was standing next to Resident #13 while assisting Resident #13 with eating, instead of sitting next to Resident #13. Interview on 11/16/22 at 9:34 A.M., with the Director of Nursing (DON) verified staff should be seated next to residents when they are assisting them with eating and standing next to a resident while assisting them with eating was not treating the resident in a dignified manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 2 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0550 Review of the facility policy titled, Resident Rights, ICF Policy, dated 05/01/22, revealed residents will be treated with dignity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 3 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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, review of the beneficiary notice list, and staff interview, the facility failed to ensure residents were provided Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms appropriately. This affected two (Residents #52 and #273) out of three residents reviewed for beneficiary notices. The census was 66. Residents Affected - Few Findings include 1. Review of the medical record for Resident #273 revealed Resident #273 was admitted on [DATE] and discharged [DATE]. Diagnoses included but were not limited to respiratory failure, muscle weakness, and diabetes. Review of the beneficiary notice list revealed Resident #273 was discharged from therapy on 10/05/22. 2. Review of the medical record for Resident #52 revealed Resident #52 was admitted on [DATE]. Diagnoses included but were not limited to dementia, chronic obstructive pulmonary disease, and femur fracture. Review of the beneficiary notice list revealed Resident #52 was discharged from therapy on 06/30/22. Interview on 11/16/22 at 9:50 A.M. with Social Services Designee (SSD) #236 revealed Notice of Medicare Non-Coverage forms are to be given out when a resident is cut from therapy to inform them of their right to appeal the insurance decision and SNF ABN's are provided for residents who choose to stay at the facility so they were properly informed of potential costs. Interview on 11/16/22 at 10:24 A.M. with the Administrator and SSD #236 revealed the facility did not provide SNF ABN's for either Resident #52 or Resident #273 both of who remained at the facility after being cut from therapy with skilled benefit days remaining. Review of facility policy titled SNF/NF Notices of noncoverage and Advanced Beneficiary notices (ABN) policy, dated 02/16/22, revealed the facility failed to implement the policy in regards to the allegation. The policy revealed the ABN was a notice a provide should give you before receiving a service if the provider had reason to believe the service would not be covered under Medicare. The facility stated they want all residents to be aware of their rights under Medicare as well as properly notifying them of what expenses may incur. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 4 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were completed as appropriate. This affected one (Resident #13) of four residents reviewed for PASARR. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record of Resident #13 revealed an admission date of 07/30/20. Diagnoses included but were not limited to generalized idiopathic epilepsy, dementia without behavioral disturbance, hemiplegia and hemiparesis, major depressive disorder, malignant neoplasm of brain, and bipolar disorder. Review of the quarterly Minimum Data Set assessment, dated 08/19/22, revealed Resident #13 had severely impaired cognition. Review of Resident #13's medical record revealed no evidence of a PASSAR having been completed since admission. Interview on 11/16/22 at 8:07 A.M., with Social Services Director (SSD) #236 verified there was no evidence a PASARR had been completed for Resident #13. SSD #236 stated Resident #13 admitted from another facility. Review of the facility policy titled PASSR Ohio Procedure, dated 01/01/20, revealed all individuals must be screened for indications of serious mental illness and ID/DD (intellectual disabilities/developmental disabilities) prior to admission. If the individual is being admitted from a competitor NF (nursing facility), the original PAS must be obtained from the current NF. Transfers are not new admissions, however the receiving NF is responsible to ensure the residents have met PAS requirements prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 5 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Based on medical record review, staff interview, and policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were completed following changes to the resident's mental health diagnoses. This affected one (Resident #63) out of four residents reviewed for PASARR. The facility census was 66. Findings include: Review of the medical record of Resident #63 revealed an admission date of 08/06/22. Diagnoses included but was not limited to cerebral infarction, anxiety disorder, schizoaffective disorder, other psychoactive substance dependence, and depression. Review of the quarterly Minimum Data Set assessment, dated 10/04/22, revealed Resident #63 had moderately impaired cognition. Review of Resident #63's most recent PASARR, completed on 08/04/22, revealed it did not include Resident #63's diagnosis of schizoaffective disorder. Review of the medical record revealed Resident #63 received a new diagnosis of schizoaffective disorder on 08/12/22. Interview on 11/16/22 at 8:09 A.M., with Social Services Director (SSD) #236 verified a new PASARR was not completed upon Resident #63 receiving a new diagnosis of schizoaffective disorder. Review of the facility policy titled, PASSR Ohio Procedure, dated 01/01/20, revealed a Resident Review (RR) is completed when a current resident meets the criteria for a change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 6 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents and/or their responsible parties were routinely invited to participate in care planning. This affected one (#05) out of two residents reviewed for care planning. The facility census was 66. Findings include: Review of the Resident #05's medical record revealed Resident #05 was admitted to the facility on [DATE] with diagnoses which included but were not limited to cerebral palsy, moderate intellectual disabilities, epilepsy, bipolar disorder, delusional disorders, and cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. Review of Resident #05's quarterly Minimum Data Set assessment, dated 11/08/22, revealed the resident was severely cognitively impaired. Review of Resident #05's care conferences from 11/14/21 to 11/14/22 revealed on 10/11/22, a care conference was conducted. There were no additional care conferences held between 11/14/21 and 11/14/22. Review of Resident #05's care conference note, dated 10/11/22, revealed Resident #05 was resting in bed but Resident #05's guardian, social services, and the dietary technician were present. Interview with Resident #05 on 11/14/22 at 2:41 P.M. revealed Resident #05 had never been invited to a care conference. Interview with the Administrator on 11/15/22 at 3:05 P.M. verified there was only one care conference held for Resident #05 between 11/14/21 and 11/14/22, and it was held on 10/11/22. Review of the facility's undated plan of care policy revealed the resident and representative will have the right to participate in the development and implementation of his or her own plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 7 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #23 revealed an admission date of 03/20/18. Diagnoses included but were not limited to Parkinson's disease, diabetes, and osteoarthritis. Residents Affected - Few Review of the Annual Minimum Data Set assessment, dated 10/10/22, revealed Resident #23 was cognitively intact. Resident #23 required extensive assistance of one person for eating. Resident #23 had physical impairments of upper extremities on both sides. Resident #23 had loss of liquids/solids from mouth when eating and drinking, and was on a mechanically altered diet. Review of the plan of care, dated 09/19/22, revealed Resident #23 was dependent on staff for meeting activity of daily living needs with interventions including total dependence of one staff for eating at all meals and snacks. Resident #23 was at risk for nutritional problems with interventions including dys mech thin liquids, to provide assistance with meals as needed, provide meals according to the diet order, and provide speech and occupational therapy as needed. Review of Resident #23's physician orders dated 06/06/22 revealed an order for a regular diet with dys mech texture. Review of Resident #23's physician orders dated 07/01/22 revealed Resident #23 was to be fed at meal times to increase intake and decrease signs and symptoms of penetration/aspiration related to self feeding. Observation on 11/14/22 at 11:54 A.M. revealed Resident #23 was attempting to eat pureed food. Resident #23 did not receive assistance from staff and was feeding herself. Resident #23's arm was shaking and about three fourths of the food on the spoon had dripped off onto Resident #23's face and was dripping down her chin and onto her clothing protector. Observation on 11/15/22 at 12:17 P.M. revealed Resident #23 was attempting to feed herself and was splattering food all over her mouth which was then dripping onto her clothing protector. No staff were observed offering to assist Resident #23 with eating. Interview on 11/16/22 at 12:07 P.M. with Speech Therapy (ST) #270 revealed the facility's pureed food had been runny. ST #270 confirmed during the lunches on 11/14/22 and 11/15/22, Resident #23 had liquid like food running down her chin. She revealed Resident #23 had shakiness in her arms due to Parkinson's disease. ST #270 revealed she was aware of the order and recommendation to assist Resident #23 with eating due to difficulty with getting the food into Resident #23's mouth. ST #270 revealed about a week ago staff informed her of Resident #23 having some difficulty with the dysphagia mechanical diet and was coughing and pocketing food so she recommended switching Resident #23 to a pureed diet. Based on medical record review, observation, and resident and staff interview, the facility failed to ensure residents who were dependent on staff assistance for activities of daily living received assistance with personal hygiene and eating. This affected two (#02 and #23) of three residents reviewed for activities of daily living. The facility census was 66. Findings include: 1. Review of the medical record for Resident #02 revealed an admission date of 11/06/06. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 8 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, Alzheimer's disease, psychotic disorder, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/01/22, revealed Resident #02 had severely impaired cognition and did not reject care. Resident #02 required extensive assistance of two staff for bed mobility, extensive assistance of one person for transfers, toileting, and personal hygiene. Review of the care plan, dated 09/08/22, revealed Resident #02 had an ADL (activities of daily living) self-care performance deficit related to CVA (cerebrovascular accident) with left hemiplegia, limited mobility, and left hand flexion contracture. Interventions included to provide extensive to total assistance for personal hygiene. Observation and interview on 11/14/22 at 10:18 A.M. revealed Resident #02 sitting up in her wheelchair in her room. Resident #02 was observed to have facial hair on her chin which measured approximately one and a half inches long. When asked, Resident #02 stated she did not want to have hair on her chin. Observation on 11/16/22 at 10:21 A.M. revealed Resident #02 laying in bed. Resident #02 still had long facial hair extending from her chin. Interview on 11/16/22 at 10:23 A.M., with Registered Nurse (RN) #255 verified Resident #02 had long facial hair extending from her chin. RN #255 confirmed residents should be checked for facial hair and trimmed on shower days as well as upon request. RN #255 confirmed it appeared it had been awhile since Resident #02's facial hair had been trimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 9 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of the staffing tool, review of staff punches, review of daily staff schedules, and staff interview, the facility failed to ensure a Registered Nurse (RN) worked in the facility at least eight consecutive hours, seven days a week. This had the potential to affect all 66 residents residing in the facility. The facility census was 66. Findings include: Review of the staffing tool on 11/15/22 revealed on Sunday, 11/13/22, the facility did not have an RN on the schedule. Review of the staff punches for 11/13/22 confirmed no RN was working on 11/13/22. Review of the daily staff schedules for 11/13/22, confirmed no RN was scheduled for that day. Interview with the Administrator on 11/15/22 at 2:00 P.M. confirmed the facility did not have an RN available to work on 11/13/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 10 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician addressed a resident's pharmacy recommendation in a timely manner. This affected one (#24) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #24's medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses which included but were not limited to schizophrenia, unspecified dementia mild with other behavioral disturbance, and diabetes mellitus due to underlying condition with other skin ulcer. Review of Resident #24's quarterly Minimum Data Set assessment, dated 11/04/22, revealed the resident was severely cognitively impaired. Review of Resident #24's physician order, dated 08/12/22, revealed Resident #24 was ordered Depakote (anticonvulsant) oral tablet delayed release 500 milligrams (mgs) give three tablets by mouth at bedtime for schizophrenia. Review of Resident #24's pharmacy recommendation, dated 07/15/22, revealed Resident #24 was overdue and it was recommended to complete a Depakote level and to add it to next lab draw and continue every six months thereafter. Further review of the pharmacy recommendation revealed the physician had not addressed the pharmacy recommendation, but staff discussed the recommendation with the physician and new orders were received to obtain a Depakote level and to continue every six months on 11/15/22. Interview with the Director of Nursing (DON) on 11/16/22 at 4:45 P.M. verified Resident #24's pharmacy recommendation dated 07/15/22 was not addressed until 11/15/22. The DON also verified the physician never signed Resident #24's pharmacy recommendation. Review of the facility's medication regimen review policy, dated 02/16/17, revealed the pharmacist will report any irregularities to the attending physician, the facility's medical director and the Director of Nursing (DON) and these reports must be acted upon in a timely manner that meets the needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 11 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure psychotropic medications were ordered for a appopriate conditions. This affected one (#269) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of the medical record for Resident #269 revealed Resident #269 was admitted on [DATE]. Diagnoses included sepsis, bactermia, bipolar disorder and chronic obstructive pulmonary disease. Review of Resident #269's physician orders dated 11/10/22 revealed orders for the following three psychotropic medications: Buspirone HCl oral tablet (antianxiety) 10 milligrams (MG) with instructions to give three times daily for mental/mood health. Lurasidone HCl ora tablet (antipsychotic) 80 MG with instructions to give one tablet at bedtime of mental/mood health. Trazodone HCl Oral tablet (antidepressant) 50 MG with instructions to give one tablet at bedtime for mental/mood health. Review of the care plan, dated 11/10/22, revealed Resident #269 was on antianxiety medication, antidepressant medication and antipsychotic medication with interventions to montor the medication, provide as ordered, and complete dose reduction attempts as required. Interview on 11/16/22 at 10:05 A.M. with Director of Nursing (DON) revealed Resident #269 had psychotropic medications ordered and Resident #269 should have a diagnosis specific to each medication and not be listed as mood or mental health. The DON was unsure why Resident #269's buspirone, lurasidone, and trazodone had been ordered for mental/mood health. Interview on 11/17/22 at 10:49 A.M. with the DON revealed when the orders come from the hospital they do not always have the correct diagnosis listed and the nurse just transcribes what is shown. Review of facility policy titled Antipsychotic Second Clinical Review, dated 03/01/19, revealed antipsychotic medications are used to treat psychosis and other serious mental health conditions. The policy revealed appropriate use of antipsychotic medications included treating an enduring condition. The Psychiatric medication must include a valid indication or reasoning including a chronic condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 12 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview, review of standardized recipes, review of facility pureed standards, and policy review, the facility failed to ensure pureed food recipes were followed and pureed foods were prepared appropriately. This had the potential to affect seven (#10, #20, #21, #23, #25, #35, and #270) out of seven residents identified by the facility as receiving pureed foods from the kitchen. The facility census was 66. Findings include: Observation and interview on 11/16/22 at 11:04 A.M. revealed [NAME] #253 added eight servings of peas to the food processor. [NAME] #253 then started the food processor and added a small amount of broth to the processor. [NAME] #253 stated she added a half teaspoon of broth for every eight ounces of peas. [NAME] #253 then removed the cover from the processor, stirred the contents, and stated she adds bread if needed to reach the desired consistency. [NAME] #253 added one slice of bread and pulsed the food processor. [NAME] #253 then poured the contents of the food processor, which appeared to have a liquid consistency, into a pan. [NAME] #253 stated she prefers an applesauce consistency when preparing pureed vegetables. Observation on 11/16/22 at 11:10 A.M. revealed [NAME] #253 placed eight servings of meatloaf in the food processor. [NAME] #253 then added seven slices of bread to the food processor and began to pulse the contents. [NAME] #23 then added approximately eight teaspoons of broth to the food processor. [NAME] #253 stated she prepares pureed meat to a pudding consistency. [NAME] #253 then scooped the contents of the food processor into a pan. Observation of tray line on 11/16/22 between 11:45 A.M. and 12:25 P.M. revealed pureed peas were scooped into divided plates and appeared in liquid form and immediately filled the bottom of the section of the divided plate. When divided plates were not used for pureed foods, the pureed peas were placed in a small bowl. Review of the recipe for pureeing peas revealed the desired number of servings should be added into the food processor and blended until smooth. Then, follow the directions on food thickener guidelines for liquid and thickener measurements. Review of the recipe for pureeing meatloaf revealed the desired number of servings should be added into the food processor and blended until smooth. Add liquid if the product needed thinning. Add commercial thickener if the product needed thickening. Interview on 11/16/22 at 12:07 P.M. with Speech Therapy (ST) #270 revealed the facility's pureed food had been runny. Interview on 11/16/22 at 1:12 P.M. with Culinary Director (CD) #226 verified the recipes for the pureed peas and pureed meatloaf indicated thickener was to be used for thickening if needed and made no mention of bread. CD #226 stated she did not receive thickener on the last food delivery. Interview on 11/16/22 at 3:44 P.M. with Dietary Technician (DT) #273 revealed all pureed foods should be prepared to a mashed potato consistency and it was too thin if it dripped off a spoon. DT #273 stated he was unaware of the kitchen staff using bread instead of thickener and confirmed this was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 13 of 14 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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 0805 not an appropriate method of pureeing foods. Level of Harm - Minimal harm or potential for actual harm Review of the facility-provided document titled Puree Standard, undated, revealed food should be able to hold its form on a flat plate without spreading, with a consistency like mashed potatoes or pudding. The policy stated never add bread to thicken anything other than a sandwich. Residents Affected - Some Review of the facility policy titled Food: Quality and Palatability, dated 09/2017, revealed food is prepared in a manner, form, and texture that meets each residents' needs. Cooks prepare food in accordance with the recipes and use proper cooking techniques to ensure color and flavor retention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 14 of 14