Inspection visit

InspectionMarch 28, 2019

NORTHWOOD SKILLED NURSING AND REHABILITATIONCMS #36568427 citations on this visit

27 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 27 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation and interview the facility failed to serve residents at the same time at the same table. This affected two residents (#11 and #55) of 15 who were in the dining room. The facility census was 65. Residents Affected - Some Findings include: Observation on 03/25/19 at 12:06 P.M., of the facilities main dining room revealed there were 15 residents seated in dining room and two staff passing out trays. There was one table with three residents (#10, #11, and #55) sitting at the same table. Resident #10 received her tray at start of service and Resident #11 and #55 who were seated with Resident #10 did not receive a tray. Staff continued to pass other trays out in the dining room randomly and not at same table. At 12:18 P.M., and Resident #11 and Resident #55 were still awaiting to be served. Resident #10 was almost finished eating. At 12:20 P.M., all residents were served in the dining room except Resident #11 and Resident #55. Interview on 03/25/19 at 12:20 P.M., with Resident #10 revealed the kitchen always got trays mixed up. Resident #11 and Resident #55 revealed they did not know why they had not received their food yet. Interview on 03/25/19 at 12:21 P.M., with Licensed Practical Nurse (LPN) #141 revealed Resident #11 and Resident #55's trays had been sent out on hall trays and they were trying to find them. Observation n 03/25/19 at 12:22 P.M., revealed Resident #11 received her tray. At 12:23 P.M., Resident #55 received her tray. Interview on 03/28/19 at 3:00 P.M., with Regional Director of Operations #192 verified they had no dining policy. She verified residents should be served at the same time. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 22 Event ID: 365684 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, the facility failed to ensure a resident received showers per his schedule and choice. This affected one resident (#9) of two residents reviewed for choices. The facility census was 64. Findings include: Review of Resident #9's medical record revealed an admission date of 04/12/16. Medical diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, Parkinson's disease, chronic obstructive pulmonary disorder, and heart failure. Review of Resident #9's care plan revised on 05/14/18 revealed he required assistance with activities of daily living due to weakness, cerebrovascular accident with left hemiparesis, chronic obstructive pulmonary disease, difficulty with balance, unsteady gait, impulsivity, and needing encouragement to bathe and complete personal hygiene. Interventions included providing extensive assistance with one staff member for bathing, showering, and personal hygiene on Tuesdays and Fridays 7:00 A.M. through 7:00 P.M. shift. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild impairment in cognition. His preferences for routine and activities revealed it was very important to choose between a tub bath, shower, bed bath, or sponge bath. He required extensive assistance with one staff member for dressing, toilet use, and personal hygiene. He required physical help in part of bathing activity with one staff assist. Review of the resident's shower sheets for February and March 2019 revealed he received showers on 02/05/19, 02/12/19, 02/19/19, 02/22/19, 02/26/19, 03/01/19, 03/05/19, 03/19/19, and 03/26/19. He was missing shower documentation for 02/01/19, 02/08/19, 02/15/19, 03/08/19, 03/12/19, 03/15/19, and 03/22/19. Interview and observation with the resident on 03/25/19 at 2:39 P.M., revealed he was scheduled for a shower two times per week, on Tuesday and Friday, however, did not always get his scheduled showers. Observation revealed the resident's hair was unkempt. The resident had unshaven facial hair of more than a days growth. Interview with State Tested Nursing Assistant (STNA) #131 on 03/27/19 at 10:27 A.M., revealed he had not refused showers when she worked with him. She stated he was supposed to get showers on Tuesdays and Fridays. Interview with the Director of Nursing (DON) on 03/27/19 at 5:11 P.M., verified the only documentation of showers received for the resident in February and March 2019 were on 02/05/19, 02/12/19, 02/19/19, 02/22/19, 02/26/19, 03/01/19, 03/05/19, 03/19/19, and 03/26/19. He was missing shower documentation for 02/01/19, 02/08/19, 02/15/19, 03/08/19, 03/12/19, 03/15/19, and 03/22/19. She verified he should have received showers every Tuesday and Friday. She had no documentation indicating the resident refused any showers. Interview with Regional Director of Operations #192 on 03/28/19 at 3:44 P.M. revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 2 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0561 did not have a policy for bathing residents. 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: 365684 If continuation sheet Page 3 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on personnel file review and staff interview, the facility failed to conduct reference checks on six of six new employees, Registered Nurse (RN) #123, Licensed Practical Nurse (LPN) #141, State Tested Nursing Assistant (STNA) #135, #137, #130, and #188. This had the potential to affect all 65 residents of the facility. Residents Affected - Many Findings include: 1. Review of RN #123's personnel file revealed a hire date of 06/01/18. There was no evidence reference checks were completed. 2. Review of LPN #141's personnel file revealed a hire date of 05/17/18. There was no evidence reference checks were completed. 3. Review of STNA #135's personnel file revealed a hire date of 04/12/18. There was no evidence reference checks were completed. 4. Review of STNA #137's personnel file revealed a hire date of 09/25/18. There was no evidence reference checks were completed. 5. Review of STNA #130's personnel file revealed a hire date of 03/06/19. There was no evidence reference checks were completed. 6. Review of STNA #188's personnel file revealed an hire date of 07/05/18. There was no evidence reference checks were completed. Interview with Regional Director of Operations #192 on 03/28/19 at 2:30 P.M., verified background checks were completed on the above six employees, however reference checks had not been completed. Review of facility policy titled Abuse Policy, dated 02/2019, revealed the facility will check applicants references from prior employees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 4 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident/resident representative in writing of the reason for a transfer to the hospital. This affected one (#11) of two residents reviewed for hospitalization. The facility census was 65. Findings include: Review of Resident #11's medical diagnoses revealed the following diagnoses; heart failure, sepsis, and paranoid schizophrenia. The resident was hospitalized on [DATE] and returned on 01/15/19. Resident #11 was then hospitalized from [DATE] until 01/26/19. Review of the comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #11's progress notes dated 01/05/19 at 4:15 A.M., revealed the resident was noted to have labored breathing and vitals were taken. Emergency services (EMS) was notified to transport the resident to the hospital. The resident was her own person and the contact person listed for emergency was unable to be contacted. The Director of Nursing (DON) of the facility was contacted, and the resident was sent to the hospital. Review of Resident #11's progress note dated 01/16/19 at 2:00 P.M., revealed he resident continued to be warm to the touch; continues to cough, and was not eating or drinking. The physician was notified and gave an order to send the resident to the emergency room. The resident left the facility at 2:30 P.M. There was no evidence the resident/and or representative being notified in writing of the reasoning for the transfer to the hospital Interview with Regional Director of Operations (RDOO) on 03/27/19 at 2:00 P.M., confirmed the resident was sent to the hospital on [DATE] and 01/16/19 and there was no evidence the resident and or resident representative were notified in writing of the reasoning for the transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 5 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #6's medical record revealed an admission date of 01/28/19 with diagnoses of moderate protein-calorie malnutrition, dyspnea, irritable bowel syndrome, anxiety, chronic respiratory failure with hypoxia, cerebral infarction (stroke), and major depressive disorder. There was no evidence a baseline care plan was created for the resident. Interview with Regional Quality Assurance Manager #194 on 03/28/19 at 2:02 P.M., verified Resident #6 did not have a baseline care plan created upon admission to the facility. Review of a facility policy titled Care Plans-Baseline revised on 12/16 revealed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty eight hours of admission. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: The initial goals of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents had baseline care plans in place. This affected three residents (#6, #57, and #364) of eight residents who were new admissions. The facility census was 65. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 03/04/19 with diagnoses including. anxiety, depression, chronic obstructive pulmonary disease (COPD), and delusional psychosis. The resident was noted to be on oxygen at two liters. There was no evidence there were any baseline care plans developed. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #57 had cognitive deficits, displayed no behaviors, received antipsychotic medication and antidepressant medications, and received oxygen therapy. His comprehensive care plan decision date on the MDS was 03/13/19. Review of physician orders dated March 2019 revealed Resident #57 had orders for antidepressant medications Remeron and Sertraline, antipsychotic medication quetiapine, and Aricept for dementia. Observation was conducted on 03/25/19 at 11:53 A.M., and on 03/26/19 at 4:11 P.M., of Resident #57 revealed he had on oxygen at three liters per minute via nasal cannula. Interview on 03/27/19 at 9:29 A.M., with Registered Nurse (RN) #194 verified Resident #57 had no baseline care plans in place. 2. Review of the medical record for Resident #364 revealed an admission date of 03/18/19 with diagnoses including depression, COPD, and acute abdominal pain. There was no evidence any baseline care plans were in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 6 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0655 Level of Harm - Minimal harm or potential for actual harm Review of physician orders dated March 2019 revealed orders for Tramadol as needed for pain for up to 30 days. Observation and interview on 03/25/19 at 11:44 A.M., with Resident #364 revealed he had oxygen at the bedside and stated he wore oxygen at night only. He stated he had pain all the time. Residents Affected - Few Interview on 03/28/19 at 2:56 P.M., with Regional Director of Operations #192 verified there were no baseline care plans in place for Resident #364's use of oxygen or for pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 7 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #3 revealed an admission date of 01/24/19 with diagoses including malignant melanoma (cancer) of skin and cerebral atheroscelosis. The resident was admitted to hospice on 03/06/19 for the diagnosis of cerebral atheroscelosis. Review of the plan of care for Resident #3 revealed it was absent for a plan of care for hospice services. This was verified by Regional Director of Operations #101 at 03/27/19 at 9:52 A.M. Based on medical record review, and staff interview the facility failed to ensure accurate comprehensive care plans were in place for three residents (#3, #11, and #57) of four reviewed for comprehensive care plans. The facility census was 65. Findings include: 1. Review of Resident #11's medical record revealed the resident returned from the hospital on [DATE] with diagnoses including heart failure, paranoid schizophrenia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severe cognitive impairment. Review of the March 2019 physician orders revealed the resident had an order for Eliquis (blood thinner) 5 milligrams (mg) one tablet twice a day. The order was initiated on 01/27/19. There was no evidence there was a care plan for the use of the anticoagulant. Interview with Regional Director of Operations #101 on 03/27/19 at 4:35 P.M., confirmed there was no care plan for the use of Eliquis and there should have been one. 3. Review of the medical record for Resident #57 revealed an admission date of 03/04/19 with diagnoses including Alzheimer's, anxiety, depression, chronic obstructive pulmonary disease (COPD) , and delusional psychosis. Review of code status paper in medical record revealed Resident #57 had a signed do not resuscitate comfort care (DNRCC) in place. Review of physician orders dated March 2019 revealed Resident #57 had orders for antidepressant medications Remeron and Sertraline, antipsychotic medication quetiapine, and Aricept for dementia. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #57 had cognitive deficits, received antipsychotic medication, antidepressant medications, and received oxygen therapy. His care plan decision date on the MDS was 03/13/19. There was no evidence Resident #57 had care plans in place for the code status, use of psychotropic medications, behaviors, oxygen therapy, cognitive status, Alzheimer's and COPD. Interview on 03/27/19 at 9:29 A.M., with Registered Nurse #194 verified Resident #57 was a DNRCC, received oxygen therapy, was on psychotropic medications, had cognitive deficits, diagnoses that included Alzheimer's and COPD and there were no care plan in place for any of them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 8 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 review of a facility policy, the facility failed to ensure an interdisciplinary care conference was held for a resident. This affected one resident (#6) of one resident reviewed for care planning. In addition, the facility failed to ensure a resident's care plan was revised timely. This affected one resident (#21) of one resident reviewed for positioning/mobility. The facility census was 65. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 01/28/19 with diagnoses including moderate protein-calorie malnutrition, dyspnea, irritable bowel syndrome, anxiety, chronic respiratory failure with hypoxia, and pleural effusion. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no impairment in cognition. Interview with Resident #6 on 03/27/19 at 1:36 P.M., revealed she has not had a care conference. She was upset as she wanted to discuss plans for discharging to her home. Review of the resident's medical record revealed no evidence a care conference had been held throughout her admission. Interview with Licensed Practical Nurse (LPN) Unit Manager #141 on 03/27/19 at 3:26 P.M., revealed the facility had not had a social services designee for approximately six months and she was was trying to fulfill these duties as well as LPN Unit Manager duties. She stated the social services staff should be ensuring resident care conferences were held. Interview with Regional Quality Assurance Manager #Nurse on 03/28/19 at 2:02 P.M. verified the resident had not had a care conference since admission to the facility. The facility did not have a policy regarding care conferences. 2. Review of Resident #21's medical record revealed an admission date 11/20/13 with diagnoses including cervicobrachial syndrome, seizures, chronic obstructive pulmonary disorder, and major depressive disorder. Review of the resident's MDS assessment dated [DATE] reveled the resident was moderately cognitively impaired. She had impairment bilaterally of upper and lower extremities. Review of the resident's care plan revealed a care plan last revised on 06/26/18 indicating the resident had an alteration in musculoskeletal status with left hand decreased muscle tone. The goal was the resident would remain free of complications such as further contracture formation, embolism and immobility through review date. Interventions included assisting the resident with the use of supportive device, left hand splint daily six to eight hours, resident permitting. Continued review of the care plan revealed the resident had potential impairment to skin integrity of the left hand related to the use of a splint. The goal was for the resident to have no complications to left hand related to splint treatment through the review date. Review of the resident's occupational therapy (OT) Discharge summary dated [DATE] revealed the resident demonstrated limited participation and reported she will never be getting out of bed again and had no reason to. The resident received training to keep her nails shorter to improve hand hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 9 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 of her left hand. It was noted she was refusing to wear her left hand splint. Level of Harm - Minimal harm or potential for actual harm Observation and interview with Resident #21 on 03/26/19 at 2:50 P.M., revealed the resident had a left hand contracture with no splint device. There was a hand splint on a table in the resident's room. The resident stated the splint was for her left hand and stated staff had not applied it in a very long time. There was no evidence the resident had an order for the splint. Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #150 on 03/27/19 at 1:26 P.M., verified the resident was not wearing her splint to her left hand and did not have an order for the splint use. Interview with Regional Director of Operations #192 on 03/27/19 at 4:14 P.M., revealed the resident refused to wear her splint during her last occupational therapy treatments in January 2019. She verified the resident's care plans were not updated to reflect the resident was no longer receiving splint services. She stated the facility did not have a policy regarding care plan revision, the facility follows the Resident Assessment Instrument (RAI) manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 10 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Based on medical record review, and staff interview, the facility failed to ensure advanced directives were completed and accurate. This affected four residents (#6, #11, #25, and #57) of six reviewed for advance directives. The facility census was 65. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 01/28/19 with diagnoses including moderate protein-calorie malnutrition, chronic respiratory failure with hypoxia, and pleural effusion. Review of the resident's physician's orders revealed an order dated 02/07/19 revealed the resident's code status was CCA (comfort care arrest). Continued review of the resident's medical record revealed no evidence of a do not resuscitate (DNR) identification form signed by the resident and physician. Interview with Regional Director of Operations (RDO) #192 on 03/27/19 at 12:25 P.M. verified the resident did not have a DNR identification form on record. 2. Review of Resident #25's medical record revealed an admission date of 01/11/19 with diagnoses including spinal stenosis, atrial fibrillation, shortness of breath, and generalized muscle weakness. Review of the resident's physician's orders dated 02/07/19 revealed the resident's code status was do not resuscitate comfort care-arrest (DNRCC-A). Continued review of the resident's medical record revealed the resident's DNR identification form was undated, was signed by the resident, however not the physician. Interview with RDO #192 on 03/28/19 at 2:19 P.M. verified the resident's DNR identification form was not signed by the physician or dated. 4. Review of Resident #11's medical record revealed an admission date of 01/27/19 with diagnoses of heart failure, hypertension, sepsis, paranoid schizophrenia, and type two diabetes. The medical record revealed a paper in the front of the medical record indicating the resident was a Full Code. Review of the March 2019 physician orders revealed there was no order identifying what Resident #11's code status was. Interview with Regional Quality Assurance Manager (RQAM) #100 on 03/27/19 at 9:27 A.M., confirmed there was no physician order identifying what Resident #11's code status was. 3. Review of the medical record for Resident #57 revealed an admission date of 03/04/19 with diagnoses including Alzheimer's, anxiety, depression, and chronic obstructive pulmonary disease. Review of code status paper in medical record revealed Resident #57 had a signed do not resuscitate comfort care (DNRCC) in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 11 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0678 Review of physician orders dated March 2019 revealed no order for code status. Level of Harm - Minimal harm or potential for actual harm Review of care plans revealed there was no care plan in place for code status. Residents Affected - Some Interview on 03/27/19 at 9:29 A.M., with Registered Nurse (RN) #194 verified Resident #57 was a DNRCC and there was no physician orders in place to address his code status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 12 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure residents had a physician order for the use of oxygen. This affected two (Resident #57 and Resident #364) of eight residents receiving oxygen therapy. The facility census was 65. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 03/04/19 with diagnoses including chronic obstructive pulmonary disease (COPD). The resident had no physician order for oxygen and no care plan for the use of oxygen. Observation of Resident #57 on 03/25/19 at 11:53 A.M. and on 03/26/19 at 4:11 P.M. Resident #57 was receiving oxygen at three liters per minute via nasal cannula. During interview on 03/26/19 at 4:11 P.M., Registered Nurse (RN) #175 stated the resident was receiving oxygen. During interview on 03/27/19 at 9:29 A.M., RN #194 verified there was no physician order for the resident to receive oxygen. 2. Review of the medical record for Resident #364 revealed an admission date of 03/18/19 with diagnoses including COPD. The resident had no physician order for oxygen and no care plan for the use of oxygen. Observation and interview on 03/25/19 at 11:44 A.M. revealed Resident #364 had oxygen at his bedside. He stated he wears oxygen at night only. During interview on 03/28/19 at 2:56 P.M., Regional Director of Operations #192 verified there was no physician order for the resident to receive oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 13 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to assess residents for pain. This affected two (Residents #47 and #364 ) of three residents reviewed for pain . The facility census was 65. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #47 revealed a readmission date of 02/24/19 with diagnoses of traumatic brain injury and atrial fibrillation. Review of the quarterly comprehensive assessment dated [DATE] revealed Resident #47 had no cognitive deficits and experienced frequent pain. The medical record contained no documentation of a pain assessment. Review of the care plan for pain revealed the resident was at risk for pain and interventions included to monitor for pain and record pain scale, anatomical location, onset, duration, aggravating factors, and relieving factors. Review of physician orders dated March 2019 revealed to assess for pain every shift using the one to ten pain scale or facial expression pain scale and as needed and administer Hydrocodone three times a day routine for pain, and Tylenol every six hours as needed for pain. Review of medication administration record (MAR) dated March 2019 revealed Resident #47 was administered Tylenol 17 times. There was no evidence on the MAR the resident's pain level was documented. Observation and interview of Resident #47 on 03/25/19 at 3:08 P.M. revealed the resident sitting on his bed watching television. He stated he always has pain and pain medications are no good. During interview on 03/28/19 at 2:55 P.M., Regional Director of Operations #192 verified there was no pain assessments being completed or documented for Resident #47 per physician orders. 2. Review of the medical record for Resident #364 revealed an admission date of 03/18/19 with diagnoses including acute abdominal pain. Review of physician orders dated March 2019 revealed orders for tramadol as needed for pain up to 30 days. Review of MAR dated March 2019 revealed he received tramadol three times. The medical record contained no documentation of a pain assessment. During interview on 03/25/19 at 11:44 A.M., Resident #364 stated he has pain all the time. During interview on 03/28/19 at 2:56 P.M., Regional Director of Operations #192 verified there was no pain assessments in place for Resident #364. Review of the facility policy titled Pain Assessment and Management Policy, dated March 2015, revealed the purpose of policy was to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes assessing for pain, identifying characteristics of pain, and monitoring the effectiveness of interventions. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, and whenever there is a significant change in condition. Assess the resident's pain routinely as needed for acute (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 14 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0697 pain or significant changes in levels of chronic pain or stable chronic pain. 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: 365684 If continuation sheet Page 15 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, policy review, and pharmacy guidelines for medication storage, the facility failed to ensure insulin was properly labeled. This affected one (200 hall medication cart) of four medication storage areas. The facility census was 65. Findings include: Observation of the 200 hall medication cart on 03/27/19 at 4:30 P.M. revealed three insulin pens in use and not labeled with the first use date or expiration date. Interview with Licensed Practical Nurse #150 at the time of observation verified the insulin pens had been used and were not labeled or dated. Review of the facility policy titled Storage of Medications, revised April 2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of facility policy Medication Storage Guidelines, dated November 2018, revealed insulin pens were to be stored at room temperature for 28 days after opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 16 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 Based on record review and interview, the facility failed to ensure a resident's laboratory test was completed as ordered. This affected one (Resident #6) of three residents reviewed for pain. The facility census was 65. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 01/28/19. The physician had a physician's order dated 03/21/19 to obtain a serum creatinine level on 03/22/19. There was no evidence in the medical record the serum creatinine level was completed. During interview on 03/27/19 at 11:25 A.M., Regional Quality Assurance Manager #194 verified the facility did not obtain the resident's serum creatinine level ordered 03/21/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 17 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review and interview, the facility failed to follow the menu and serve all items listed; failed to follow the recipe for puree foods; failed to provide finger foods as ordered; and failed to meet residents nutritional needs. This affected 64 residents who receive food from the kitchen. The facility census was 65. Findings include: 1. During observation of the dining room and hall trays on 03/25/19 P.M. from 12:00 P.M. to 12:36 P.M., no dinner roll was served as listed on the menu. Review of facility menu for 03/25/19 included a dinner roll with the meal. During interview on 03/25/19 at 12:29 P.M., Dietary Manager #145 stated dinner rolls were not served because they did not look good and no substitution was served for the rolls. 2. During observation of puree food preparation on 03/25/19 at 4:20 P.M., Dietary [NAME] #171 placed two pieces of chicken in the food processor and added an unmeasured amount of water. He started the food processor and added an additional unmeasured amount of water. During interview at the time of the observation, Dietary [NAME] #171 stated he had either two or three residents on puree and that two pieces of chicken was enough to get him through supper. He stated there was recipes to follow and pointed to a binder and stated the recipes were all in there. During interview on 03/25/19 at 4:30 P.M., Dietary Manager #145 and she stated the facility does have binders with recipes but they do not go by recipes, they make stuff from scratch. During interview on 03/27/19 at 2:16 P.M., Dietician #196 stated dietary staff are expected to follow the recipes for pureed foods. Water is not considered a nutritive liquid and dietary staff should have used a nutritive liquid, broth, or milk to puree the chicken. During interview on 03/28/19 at 11:30 A.M., Dietary Manager #145 and Dietary [NAME] #134 stated the facility had three residents, Residents #22, #23 and #373, who were on puree diets. During interview on 03/28/19 at 3:00 P.M., Regional Director of Operations #192 verified they had no policy in reference to dining, following the menus or following recipes. Review of the facility's puree recipe for chicken supreme revealed to remove desired number of servings and add nutritive liquid, milk, or broth. Blend to desired consistency, and add approved thickener to achieve desired consistency as needed. Serving size is one four ounce chicken breast. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 18 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to have proper sanitizing of dishes, failed to ensure food was not out dated, and failed to maintain a clean environment in the kitchen. This had the potential to affect 64 residents who received meals from the kitchen; one resident received no food by mouth. The census was 65. Findings include: 1. During observation on 03/25/19 at 9:00 A.M., there was a large amount of a black substance on the ceiling of the dry storage room, back hallway and by the dishwasher. During interview on 03/25/19 at 9:00 A.M., Dietary Manager #145 stated they had a cleaning party a couple of days ago and they washed the walls. The facility has trouble with condensation from the dishwasher and they were getting a new dishwasher this week. During interview on 03/28/19 at 10:00 A.M., Maintenance Staff #161 verified there was a black substance on the walls and ceiling of the kitchen. He stated they had a fan on the roof that quit working that draws the moisture out and they did not know that it was not working. 2. During observation on 03/25/19 at 9:00 A.M. of the milk cooler, a crate half full of individual skim milk cartons were dated to be used by 03/22/19. Observation of the bread racks revealed eight loafs of bread dated 03/22/19, one loaf of bread dated 03/16/19, two packs of hot dog buns dated 03/18/19, part of an open pack of hot dog buns dated 03/18/19, part of a bag of hamburger buns dated 03/11/19, one pack of hamburger buns dated 03/12/19, two packs of hamburger buns dated 03/23/19, and located on kitchen counter was two open loafs of bread dated 03/16/19 and 03/22/19. During interview on 03/25/19 at 9:00 A.M., Dietary Manager #145, she verified the milk and bread and buns were outdated. 3. During observation on 03/25/19 at 10:20 A.M., Dietary Staff #126 tested the dishwasher with a chemical test strip twice in the machine and there was no indication of any presence of chemicals. She then tested a pan that ran through dishwasher and the chemical test strip was not showing any presence of chemicals. During interview on 03/25/19 at 10:20 A.M., Dietary Manager #145 verified the chemical test strip was not showing any presence of chemicals and they would use the three sink method for washing dishes and notify the company that services the dishwasher. During telephone interview on 03/25/19 at 10:34 A.M. with Technician #195, he stated the facility has a chemical low temperature dishwasher and wash was to be at 140 degrees Fahrenheit (F), rinse at 120 degrees F, and chemical test strip should read between 100 and 200 parts per million (ppm). During observation on 03/26/19 at 4:10 P.M. of the dishwasher, Dietary Manager #145 ran a test strip through the machine and the strip indicated no chemicals in dishwasher. She proceeded to run several test strips with no results. She tested the water and by placing strip on dishes running them through and the test strip indicated no chemicals. At that time, Dietary Manager #145 stated the chlorine test strip should be indicating 100 to 200 ppm. She stated they check it first thing in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 19 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0812 mornings and then before lunch and supper. Level of Harm - Minimal harm or potential for actual harm Observation was conducted at 4:20 P.M. of Dietary Staff #156 checked the sanitizer and the container was almost empty. The container was changed and after testing the chemicals again, the test strip indicated no chemicals. Residents Affected - Many During interview at 4:30 P.M., Dietary Manager #145 contacted the service representative and suggested priming the chemical container. The chemicals were tested again at 4:40 P.M. and registered between 100 and 200 ppm. Review of the facility policy titled Dishwashing Machine Use Policy, dated March 2010, revealed a supervisor will check the dishwashing machine for proper concentration of sanitizer solution measured as parts per million after filling the dishwashing machine and once a week thereafter. If chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until parts per million are adjusted. Review of the facility policy titled Refrigerators and Freezers Policy, dated December 2014, revealed the facility will observe food expiration guidelines. All food shall be appropriately dated to ensure proper rotation by expiration dates. Use by dates will be completed with expiration dates on all prepared food. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Supervisors will be responsible for ensuring food items in pantry and refrigerators are not expired or past perish dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 20 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 record review, interview and policy review, the facility failed to implement a Legionella water management program. This had the potential to affect all 65 residents. Residents Affected - Many Finding include: Review of the document titled worksheet to identify buildings at increased risk for Legionella growth and spread, dated 03/24/19, revealed the facility needed a water management program. Interview with Regional Quality Assurance Manager on 03/28/19 at 3:15 P.M. verified that the water management program had not been implemented at this time. Review of facility policy titled Legionella Water Management Program, dated July 2017, revealed number five, letter b of the policy states that the will have a detailed description and diagram of the water system in the facility including the following 1). receiving, 2) cold water distribution, 3) heating, 4) hot water distribution, and 5) waste. Letter C states that the facility will identify areas in the mater system that could encourage the growth and spread of Legionella or other waterborne bacteria. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 21 of 22 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to provide a clean and well maintained resident smoking area that was free from used smoking materials. This affected 12 ( Resident #2, #5, #6, #9, #12, #20, #34, #47, #54, #58, #364, and #369 ) residents in the facility that are current smokers. The facility census was 65. Residents Affected - Few Findings include: During observation of the facility smoking area on 03/25/19 at 4:00 P.M., two plastic flower pots and one ceramic flower pot contained multiple cigarette butts. These flower pots were located next to facility entrance and approximately 15 feet from the smoking area. During interview on 03/25/19 at 4:15 P.M., Licensed Practical Nurse (LPN) #141 verified there was multiple cigarette buts in the three flower pots and stated they should not be there, that there was a trash can for the butts. She stated they must have done it over the weekend. LPN #141 asked Resident #47 at the time of the interview about the cigarette buts in flower pots. The resident stated they put them there at night time because that is where they smoke due to no light in smoking area. During interview on 03/25/19 at 4:30 P.M. with the Director of Nursing and with Regional Director of Operations #192, it was verified there should not be any cigarette butts placed in flower pots as these were not approved receptacles. Review of the facility policy titled Smoking Policy, dated July 2017, revealed the facility shall establish and maintain safe resident smoking practices. Smoking is only permitted in designated resident smoking areas which are located outside of the building. Ashtrays are emptied only into designated receptacles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 22 of 22

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Citations

27 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0926GeneralS&S Dpotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0770GeneralS&S Dpotential for harm
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0711GeneralS&S Fpotential for harm
F711 - Physician Visits
Provide a written emergency evacuation plan.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0607GeneralS&S Cno actual harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0678GeneralS&S Epotential for harm
F678 - Personnel provide basic life support, including CPR, to a resident
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0131GeneralS&S Epotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
0343GeneralS&S Fpotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
0912GeneralS&S Fpotential for harm
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.

FAQ · About this visit

Common questions about this visit

What happened during the March 28, 2019 survey of NORTHWOOD SKILLED NURSING AND REHABILITATION?

This was a inspection survey of NORTHWOOD SKILLED NURSING AND REHABILITATION on March 28, 2019. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at NORTHWOOD SKILLED NURSING AND REHABILITATION on March 28, 2019?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have policies on smoking."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 28, 2019