Inspection·July 2, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as receiving an anticoagulant during the assessment period. Review of the plan of care for Resident #11 dated 03/26/25 revealed resident is at risk for abnormal bleeding or hemorrhage related to anticoagulant therapy. Interventions include administering medications as prescribed, avoid activities that could cause injury, monitor for signs and symptoms of bleeding, obtain and monitor laboratory results, and review medications for adverse interactions. Review of the active physician orders for Resident #11 revealed an order for Xarelto 20 milligrams (mg) one tablet daily for left atrial thrombus dated 03/24/25. Review of the MAR for the month of March 2025 for Resident #11 revealed resident received Xarelto as ordered beginning on 03/24/25. Review of the Medication Error Report dated 03/24/25 for Resident #11 revealed Xarelto 20 mg was not entered into the electronic medical record during the transition to the new software effective on 03/01/25. Immediate corrective actions included notification of the physician to restart orders and obtain an echocardiogram. Further review of the medication error report revealed the resident representative was notified. Interview on 07/02/25 at 12:00 P.M. with DON verified the medication error occurred and the physician and Resident #11's representative was notified. DON verified the echocardiogram was completed without any negative findings. 3. Review of current Resident #19 revealed an admission date of 03/28/25 with diagnoses including chronic obstructive pulmonary disease, dementia, kidney disease, and type two diabetes with polyneuropathy. Review of the comprehensive MDS assessment dated [DATE] for Resident #19 revealed an intact cognition. Resident #19 required set up assistance for meals, supervision for bed mobility and transfers and moderate assistance for toileting. Review of the plan of care for Resident #19 dated 04/15/25 revealed resident has actual and potential for pain related to arthritis, disc disease, obesity and type two diabetes with polyneuropathy. Interventions include administering medications as ordered, encourage the resident to request pain medication as needed, monitoring changes in mood and usual activities and effectiveness of pain medication. Review of the active physicians orders for Resident #19 revealed an order dated 04/05/25 for hydrocodone-acetaminophen tablet 5-325 mg give one tablet three times a day and pregabalin 50 mg one tablet two times a day for pain. Review of the MAR for the month of April 2025 for Resident #19 revealed hydrocodone-acetaminophen tablet 5-325 mg give one tablet three times a day and pregabalin 50 mg one tablet two times a day for pain were signed off by nursing staff as administered on 04/19/25 at 6:00 P.M. Further review of the individual patient-controlled substance administration record for Resident #19's pregabalin and hydrocodone-acetaminophen revealed they were not signed out as administered on 04/19/25. Review of the medication error report dated 04/28/25 for Resident #19 revealed on 04/19/25 at 6:00 P.M. the resident did not receive the pregabalin and hydrocodone-acetaminophen as ordered. Further review of the report revealed the Nurse Practitioner (NP) and the residents' power of attorney were notified of the error on 04/21/25. Interview on 07/02/25 at 12:00 P.M. with the DON verified Resident #19 did not receive prescribed medication (pregabalin and hydrocodone-acetaminophen) as ordered on 04/19/25 at 6:00 P.M. 4. Review of current Resident #29 medical record revealed an admission date of 04/01/24 with diagnoses including anoxic brain damage, hypertensive heart disease, heart failure and peripheral autonomic neuropathy. Review of the quarterly MDS assessment dated [DATE] for Resident #29 revealed an intact cognition. Resident #29 was coded as dependent for eating and toileting assistance. Resident #29 required maximum assistance with bed mobility and transfers. Resident was coded as having pain during the assessment period. Review of the plan of care for Resident #29 dated 04/21/25 revealed resident has potential for pain related to inconsistent bowel pattern, contractures, head trauma, headaches, immobility, and verbal complaints of pain. Interventions include administer medication as ordered, encourage the resident to request pain medication as needed, monitoring changes in mood and usual activities and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365505 If continuation sheet Page 2 of 3 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 365505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Green Rehabilitation and Healthcare Center 1315 Kitchen Aid Way Greenville, OH 45331 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete effectiveness of pain medication. Review of the active physician orders for Resident #29 revealed an order for Pregabalin give 25 mg by mouth three times a day related to idiopathic peripheral autonomic neuropathy dated 02/18/2025. Review of the MAR for Resident #19 for the month of April 2025 revealed the Pregabalin was signed as administered on 04/19/25 at 6:00 P.M., by the nurse. Review of the medication error report dated 04/28/25 for Resident #29 revealed the medication Pregabalin give 25 mg tabled was not administered as ordered. Interview with resident denied any complaints of pain related to the incident. Further review of the document revealed the physician and the resident representative were notified. Interview on 07/02/25 at 12:00 P.M. with DON verified Resident #29's Pregabalin was not signed off on the individual patient-controlled substance administration record indicating it was not administered on 04/28/25. DON stated with the recent sale of the facility and the move to the new electronic health record the controlled substance record was unable to be located at the time of the survey. Review of the facility policy titled Medication Errors dated 09/2021, stated the medication error report should be completed in the electronic health record with each error. Medication errors are to be reported to the physician and the director of nursing. The deficient practice was corrected on 05/18/25 when the facility implemented the following corrective actions: Review of the Episodic Event/Past Non-Compliance document revealed the date of the event was 03/01/25. The form was documented as completed on 05/18/25. Facility documented medication errors occurred from transcription at the time of change over to the new medical record software due to the sale of the facility. Nurses were manually inputting all orders into the new system when some of the errors occurred. As a result of the errors all medication records of residents in the facility at the time of the change of owners were audited. No further medication errors were noted. On 05/01/25 a medication audit was completed for all residents receiving levothyroxine in the facility. All medication orders were confirmed correct and laboratory results for thyroid levels were confirmed or ordered to ensure levels were within normal limits. On 05/05/25 all new admissions for the last 30 days will have medication and treatment audits to ensure medications are entered into the electronic health record accurately. Fifteen resident records were identified as new admissions. Each record was reviewed by two separate nurses and documented on the new admission order check verification form. No further concerns were identified regarding medication administration. On 05/13/25, audits for residents identified as receiving thyroid medications were completed without any additional negative findings. On 05/18/25, audits for all new admissions in the last thirty days were completed and no further concerns were identified regarding medication administration. Review of the facility's new admission order check verification documentation dated 05/07/25 through 06/24/25 revealed no new medication errors. By 05/18/25, the DON or designee completed in-service training with all nurses regarding medication administration policies and procedures. This deficiency represents non-compliance investigated under the Complaint Number OH00165552 (1377615). Event ID: Facility ID: 365505 If continuation sheet Page 3 of 3