Health inspection·February 18, 2025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Insulin Glargine insert dated 08/01/22 revealed to perform a safety test: Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Review of Insulin Aspart insert dated 02/01/23 revealed giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select two units hold the pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in, the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the pen. Review of the facility insulin reference guide updated 02/01/24 revealed Insulin Glargine pen and Insulin Aspart flexpen has a pen priming requirement of two units. This deficiency represents non-compliance investigated under Complaint Number OH00161835. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 2 of 4 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 02/18/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, policy review, and staff interview the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections when they failed to use proper hand hygiene during a dressing change, and failed to follow enhanced barrier precautions. This affected one (Resident #74) of three Residents reviewed for wounds. The facility census was 81. Residents Affected - Few Findings include: Record review of Resident #74 revealed an admission date of 10/02/24 with pertinent diagnoses of Alzheimer's disease, encounter for gastrostomy, convulsions, anxiety disorder, major depressive disorder, dementia, hypertension, atrial fibrillation, and cognitive communication deficit. Review of the 01/04/25 five day Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired. Review of a Physicians Order dated 01/20/25 revealed left heel-cleanse with normal saline, pat dry, apply medical grade honey, cover with silicone bordered super-absorbent dressing every night shift for wound care and as needed. Review of a Physicians Order dated 01/22/25 revealed enhanced barrier precautions related to Percutaneous Endoscopic Gastrostomy (PEG) tube, wound dressing. Review of a Physicians Order dated 02/13/25 revealed sacrum-cleanse with Dakins (debriding and wound cleanser) half strength, pat dry, skin prep periwound, apply Dakins fluffed gauze, cover with silicone bordered super-absorbent dressing every shift for wound care and as needed. Observation on 02/13/25 at 10:37 A.M. revealed Certified Nurse Aide (CNA) #112 and Licensed Practical Nurse (LPN) #122 completing incontience care for Resident #74. There was a sign on the door stating the Resident was on enhanced barrier precautions. Neither CNA #112 or LPN #122 put on gowns while providing incontience care or wound care for the resident. Observation of LPN #122 providing wound care on 02/13/25 at 10:46 A.M. revealed she gathered supplies, border silicone dressing, medihoney, normal saline, and Dakins 1/2 strength. LPN #122 washed hands, donned glove started wound dressing on the left heel/foot. She removed the old dressing, and she did not remove her soiled gloves. LPN #122 was then observed to used normal saline and gauze to clean the wound and then apply medihoney on the clean dressing and place the dressing on the left heel wound and dated the wound dressing. LPN #122 removed her gloves and donned clean gloves without completing hand hygiene. LPN #122 was then observed to remove the coccyx wound dressing, then LPN #122 removed and donned one glove without completing hand hygiene, and was then observed to cleaned the coccyx wound with gauze and Dakins solution. LPN #122 then applied Dakins soaked gauze to wound and covered the gauze with a bandage. The wound dressing was completed at 10:54 A.M. Interview with LPN #122 on 02/13/25 at 10:57 A.M. verified she and CNA #112 did not wear gowns while providing care to Resident #74 who is on enhanced barrier precautions. LPN #122 verified she did not change gloves after removing a soiled dressing and did not wash her hands or use alcohol based hand rub after removing soiled gloves multiple times during wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365424 If continuation sheet Page 3 of 4 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 02/18/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the 04/01/24 facility Enhanced Barrier Precautions policy revealed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include: providing hygiene, and wound care. Review of the 02/25/22 facility Personal Protective Equipment Gloves policy revealed gloves are worn when there is potential contact with blood, body fluid, tissue from mucus membranes, non-intact skin or contaminated surfaces or equipment is anticipated. Perform hand hygiene before donning and after doffing gloves. Perform hand hygiene before and after the use of non-sterile gloves. Event ID: Facility ID: 365424 If continuation sheet Page 4 of 4