Inspection·July 26, 2021

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, resident and staff interview and record review the facility failed to post the past survey results in a conspicuous area that was readily available to residents and their representatives. The affected all 54 residents in the facility. Residents Affected - Many Findings include: Observation on 07/19/21 at 8:00 A.M. on entrance to the facility, the past survey results were not located in the lobby common area. Further into the building, observation was made of multiple peg boards with various posted information. No mention of the location of the past survey results were posted on the information boards. Interviews and observations during Resident Council Meeting on 07/21/21 at 11:30 A.M. with Residents #30, #6, and Resident #7, all three residents confirmed they attend resident council meetings regularly. Interview revealed the residents were unaware the past survey results were required to be available to them for review. The residents did not know the location of the past survey results. Observations on 07/21/21 at 11:40 A.M. of the common area lobby and common area information boards revealed no posted survey results or no instructions regarding location of the survey results. During interview on 07/21/21 at 11:45 A.M. with Registered Nurse (RN) #702 confirmed the past survey results were not located in an accessible area for residents and representatives to review. RN #702 revealed the survey results were located in a binder, behind the reception desk. The RN produced a black binder from behind the reception desk. RN #702 confirmed the location was not conspicuous and that residents and representatives have to ask facility staff to review past survey results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 2 of 13 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 07/26/2021 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 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure residents were free from prolonged quarantine. This affected three (Residents #2, #7, and #18) of five residents in quarantine. The census was 54. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 03/02/20 with diagnoses including chronic obstructive pulmonary disease, depression, and irritable bowel syndrome. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment. Review of Resident #2's immunization records revealed Resident #2 received the first dose of the COVID-19 vaccine on 12/22/20 and received the second dose on 01/12/21. Review of the physician order dated 06/30/21 revealed Resident #2 was placed in droplet precautions and the droplet precautions were discontinued on 07/21/21. Review of the health status note dated 06/30/21 revealed Resident #2 complained of a dry cough. Review of the medical record for Resident #2 revealed no evidence she had left the facility at any time during her quarantine from 06/30/21 to 07/21/21. Review of Resident #2's PCR COVID-19 tests collected on 06/21/21, 06/29/21, and 06/30/21 revealed all were negative for COVID-19. Review of the point of care COVID-19 test dated 06/30/21 revealed Resident #2 was negative for COVID-19. Interview with Registered Nurse (RN) #705 on 07/19/21 at 12:04 P.M. revealed Resident #2 was placed in quarantine because she developed symptoms of COVID-19. The interview further revealed she was tested for COVID-19 and tested negative. The interview further revealed Resident #2's symptoms had improved since being placed in quarantine. Interview with Resident #2 on 07/19/21 at 4:10 P.M. revealed she had been in quarantine for roughly two and a half weeks. Resident #2 was observed to be residing in isolation on the COVID-19 quarantine unit at the time of the interview. Interview with Corporate Nurse (CN) #999 on 07/22/21 at 10:34 A.M. revealed she spoke with Communicable Disease Nurse (CDN) #998 at the local health department and she advised CN #999 to quarantine residents who were fully vaccinated and symptomatic until they symptom free for 72 hours. Interview with Director of Nursing (DON) on 07/22/21 at 2:35 P.M. revealed Dietary Aide #1001 tested positive for COVID-19 and worked in the facility for a few shift prior to testing positive for COVID-19 which is why the facility considered Resident #2 to have been potentially exposed. Review of Dietary Aide #1001's COVID-19 test collected on 06/18/21 revealed Dietary Aide #1001 tested positive for COVID-19 and the positive test result was reported on 06/19/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 3 of 13 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 07/26/2021 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 0603 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #7 revealed an admission date of 06/04/20 with diagnoses including paranoid schizophrenia, anxiety, depression, and bipolar disorder. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. Residents Affected - Some Review of Resident #2's immunization records revealed Resident #7 received the first dose of the COVID-19 vaccine on 12/22/20 and received the second dose on 01/12/21. Review of the physician order dated 06/22/21 revealed Resident #2 was placed in droplet precautions and there was no stop date indicated for the droplet precautions. Review of the health status note dated 06/21/21 at 6:30 P.M. revealed Resident #7 complained of a cough although no cough was noted. Further review of the note revealed Resident #7's voice was slightly hoarse, his temperature was 98.0 degrees Fahrenheit, and a call was placed to the on call supervisor who advised to transfer Resident #7 to the COVID-19 quarantine unit. The note further revealed Resident #7 was notified, was agreeable, and a rapid COVID-19 test was performed which was negative. Review of the medical record for Resident #7 revealed no evidence he had left the facility at any time since being moved to the COVID-19 quarantine unit on 06/21/21. Review of Resident #7's point of care COVID-19 test dated 06/21/21 revealed he was negative for COVID-19. Review of Resident #7's PCR COVID-19 test collected on 06/21/21 and 06/29/21 revealed both tests were negative for COVID-19. Review of the psychiatry note dated 07/19/21 revealed Resident #7's depression was under control and Resident #7 verbalized his cough was much improved. Interview with RN #705 on 07/19/21 at 12:04 P.M. revealed Resident #7 was placed in quarantine because he developed symptoms of COVID-19. The interview further revealed he was tested for COVID-19 and tested negative. The interview further revealed Resident #7's symptoms had improved since being placed in quarantine. Interview with Resident #7 on 07/20/21 at 9:10 A.M. revealed he had been in quarantine for about three weeks, had a cough and didn't feel too well. The interview further revealed Resident #7 had been tested for COVID-19 and was negative. Resident #7 stated it can be difficult at times being in quarantine for so long. Resident #7 was observed under isolation precautions on the COVID-19 quarantine unit at the time of the interview. Interview and observation on 07/21/21 at 3:00 P.M. revealed Resident #7 was in his room on the COVID-19 quarantine unit and was observed sitting in his bed with the television off. The interview revealed had been in quarantine for about three to four weeks due to having a cough. Resident #7 stated that he was depressed but had always struggled with depression. Resident #7 further stated that his depression had gotten somewhat worse since being quarantined by himself for the past several weeks. The resident shared that he told his physiatrist this when he saw him for an appointment two to three days ago. The resident further revealed that he asked RN #705 when he could come off isolation and she told him when his cough is gone. 3. Review of the medical record for Resident #18 revealed an admission date of 05/01/18 with diagnoses including chronic obstructive pulmonary disease, COVID-19, and heart failure. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #18 had severe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 4 of 13 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 07/26/2021 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 0603 cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Review of Resident #18's immunization records revealed Resident #18 received the first dose of the COVID-19 vaccine on 12/22/20 and received the second dose on 01/12/21. Residents Affected - Some Review of the physician order dated 06/30/21 and 07/01/21 revealed Resident #18 was placed in droplet precautions on 06/30/21 and the droplet precautions were discontinued on 07/19/21. Review of the health status note dated 06/29/21 revealed Resident #18 continued to have intermittent coughing. Review of the medical record for Resident #18 revealed no evidence he had left the facility at any time during his quarantine from 06/30/21 to 07/19/21. Review of Resident #18's PCR COVID-19 tests collected on 06/21/21, 06/29/21, and 06/30/21 revealed all were negative for COVID-19. Review of the point of care COVID-19 test dated 06/30/21 revealed Resident #18 was negative for COVID-19. Interview with RN #705 on 07/19/21 at 12:04 P.M. revealed Resident #18 was placed in quarantine because he developed symptoms of COVID-19. The interview further revealed he was tested for COVID-19 and tested negative. The interview further revealed Resident #18's symptoms had improved since being placed in quarantine. Observation of the COVID-19 quarantine unit on 07/19/21 at 12:04 P.M. revealed Resident #18 resided on the COVID-19 quarantine unit. Interview with CN #999 on 07/22/21 at 10:34 A.M. revealed she spoke with CDN #998 at the local health department and she advised CN #999 to quarantine residents who were fully vaccinated and symptomatic until they symptom free for 72 hours. Interview with CDN #998 on 07/22/21 at 12:44 P.M. revealed if a resident was fully vaccinated, experiencing symptoms, and was possibly exposed to COVID-19 then she would recommend the facility to complete both a rapid COVID-19 test and PCR COVID-19 test. The interview further revealed if both of the tests were negative then she would advise the facility to continue quarantining the potentially exposed resident for 14 days. Interview with DON on 07/22/21 at 2:35 P.M. revealed Dietary Aide #1001 tested positive for COVID-19 and worked in the facility for a few shift prior to testing positive for COVID-19 which is why the facility considered Resident #18 to have been potentially exposed. Review of Dietary Aide #1001's COVID-19 test collected on 06/18/21 revealed Dietary Aide #1001 tested positive for COVID-19 and the positive test result was reported on 06/19/21. Review of the facility policy titled COVID-19 Emergency Planning and Response Plan, updated May 2021, revealed residents with suspected or known exposure to COVID-19 will be kept in their room for 14 days post exposure, placed in droplet precautions, and monitored daily for signs and symptoms. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with suspected SARS-CoV-2 infection can be made based upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 5 of 13 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 07/26/2021 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete having negative results from at least one respiratory specimen tested using an FDA-authorized laboratory-based NAAT to detect SARS-CoV-2 RNA. Review of the Centers for Disease Control Guidance titled Discontinuation of Transmission-Based Precautions and Disposition of Patients with SARS-CoV-2 Infection in Healthcare Settings, last updated 06/02/21, revealed the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with suspected SARS-CoV-2 infection can be made based upon having negative results from at least one respiratory specimen tested using an FDA-authorized laboratory-based NAAT to detect SARS-CoV-2 RNA. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and performing a second test for SARS-CoV-2 RNA. If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue Transmission-Based Precautions can be made using the symptom-based strategy described above. Ultimately, clinical judgement and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. Event ID: Facility ID: 365684 If continuation sheet Page 6 of 13 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 07/26/2021 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident #47 revealed an admission date of 02/11/21. Medical diagnoses included non-traumatic brain injury. Residents Affected - Few Review of the admission MDS, dated [DATE], revealed it was very important to the resident to go outside for fresh air and participate in religious activities. She was moderately cognitively impaired. Review of the activity calendar from 07/01/21 through 07/31/21 revealed there wasn't any scheduled activities to go outdoors. Review of documentation from 07/01/21 through 07/18/21 revealed Resident #47 didn't go outside and there wasn't an activity to go outside documented. The documentation had hymns in the morning on 07/11/21 and 07/18/21, but there was no documentation about Resident #47's participation. During observation on 07/19/21 at 11:02 A.M., the resident was lying in bed. On 07/20/21 at 8:01 A.M. care was provided. Staff did not offer any activities at this time. On 07/21/21 at 11:00 A.M., the resident was lying in bed. On 07/22/21 at 10:00 A.M. she was again lying in bed. During interview on 07/19/21 at 11:04 A.M., Resident #47 stated the activities didn't meet her interest and she wanted to go outside and wasn't able to go out. Review of the activity calendar for 07/20/21 revealed trivia at 11:00 A.M. and room visits at 1:30 P.M. Observations were made at these times revealed neither activity was provided. Review of the activities calendar for the month of July revealed a ball toss activity was scheduled for 07/21/21 at 10:00 A.M. Observations of the activity room on 07/21/21 at 10:05 A.M., 10:15 A.M., and 10:30 A.M. revealed the Activity Director sitting in the activity room alone. There was no ball toss being provided. Interview with State Tested Nurse Aide (STNA) #518 on 07/22/21 at 1:47 P.M. revealed the previous activities director quit around 06/30/21, and the activities have suffered across the whole building since she left. She felt the activities have not met the needs of the residents since the previous activity director left. STNA #518 stated there have been minimal structured activities since the previous activity director left. Based on observation, interview, and record review, the facility failed to ensure activities were completed as scheduled and met the needs of the residents. This affected three (Residents #10, #43 and #47) of 54 residents in the facility. The census was 54. Findings include: 1. Observation of Resident #10, Resident #43, and the memory care unit on 07/19/21 at 10:23 A.M. revealed Resident #10 was observed in his bed, Resident #43 was observed in her bed, and no structured activities were observed occurring in the memory care unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 7 of 13 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 07/26/2021 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident #10, Resident #43, and the memory care unit on 07/19/21 at 2:22 P.M. revealed Resident #10 was seated in the common area, Resident #43 was observed in her bed, and no structured activities were observed occurring in the memory care unit. 2. Review of the medical record for Resident #10 revealed an admission date of 04/06/21 with diagnoses including dementia, hypothyroidism, and schizoaffective disorder. Review of the admission minimum data set assessment dated [DATE] revealed staff was unable to complete the brief interview for mental status with Resident #10. Review of the comprehensive care plan revealed Resident #10 enjoyed Reds games on television, one to one interaction with staff, and listening to country music and bluegrass. Further review of the comprehensive care plan revealed Resident #10 will have activity opportunities daily. Review of the activity log dated 07/01/21 through 07/18/21 revealed Resident #10 was not marked as participating in any activities on 07/01/21, 07/04/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/09/21, 07/12/21, 07/13/21, 07/14/21, 07/15/21, 07/16/21, and 07/18/21. Observation of Resident #10 and the memory care unit on 07/21/21 at 10:02 A.M. revealed Resident #10 was laying in bed and no structured activities were observed occurring in the memory care unit. Observation of Resident #10 and the memory care unit on 07/21/21 at 4:25 P.M. revealed Resident #10 was seated in the common area of the memory care unit. The television was observed to be on however no residents were actively engaged in watching the television and no structured activities were observed occurring in the memory care unit. 3. Review of the medical record for Resident #43 revealed an admission date of 05/06/21 with diagnoses including hypertension, diabetes mellitus type two, and osteoporosis. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #43 had severe cognitive impairment. Review of the activity log dated 07/01/21 through 07/18/21 revealed Resident #10 was not marked as participating in any activities on 07/01/21, 07/02/21, 07/03/21, 07/04/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/10/21, 07/11/21, 07/12/21, 07/13/21, 07/14/21, 07/15/21, 07/17/21 and 07/18/21. Observation of Resident #43 and the memory care unit on 07/19/21 at 10:23 A.M. revealed Resident #43 was observed in her bed and no structured activities were observed occurring in the memory care unit. Observation of Resident #43 and the memory care unit on 07/19/21 at 2:22 P.M. revealed Resident #43 was observed in her bed and no structured activities were observed occurring in the memory care unit. Observation of Resident #43 and the memory care unit on 07/21/21 at 10:02 P.M. revealed Resident #43 was observed laying in bed and no structured activities were observed occurring in the memory care unit. Observation of Resident #43 and the memory care unit on 07/21/21 at 4:25 P.M. revealed Resident #43 was seated in the common area of the memory care unit. The television was observed to be on however no residents were actively engaged in watching the television and no structured activities were observed occurring in the memory care unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 8 of 13 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 07/26/2021 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 and interview, the facility failed to timely address a resident's pain. This affected one (Resident #203) of one resident reviewed for pain management. The census was 54. Residents Affected - Few Findings include: Review of the medical record for Resident #203 revealed an admission date of 07/09/21 with diagnoses including congestive heart failure, cerebral infarction, and chronic obstructive pulmonary disease. Review of the admission minimum data set assessment dated [DATE] revealed Resident #203 had severe cognitive impairment. Review of the skilled nursing note dated 07/10/21 revealed Resident #203 reported a pain level of four out of ten and staff completed non-medication interventions for pain. Review of the health status note dated 07/10/21 at 8:58 A.M. revealed Resident #203 complained of pain and a new order was received for routine pain medication. Review of the nursing note dated 07/10/21 at 3:08 P.M. revealed Physician Assistant (PA) #1005 ordered Norco Tablet 5-325 milligram (mg), give one tablet by mouth every eight hours for pain. The pharmacy would send the medication as soon as the prescription was received from PA #1005. Review of the nursing note dated 07/10/21 at 8:57 P.M. revealed Resident #203 had an order for eucerin cream, apply to bilateral lower extremities topically every night shift for dry skin and apply to bilateral lower extremities around wounds prior to wrapping with Kerlix. The resident refused to allow the nurse to move her legs enough to wrap them and stated it hurts too (expletive) bad. Review of the nursing note dated 07/10/21 at 9:10 P.M. revealed the pharmacy was waiting for the signed prescription from the physician for the order for Norco. Review of the nursing note dated 07/10/21 at 9:54 P.M. revealed Resident #203 had an order to cleanse open area to right lower extremity with normal saline, apply medihoney and non-adhesive dressing, wrap with ABD pad and Kerlix daily and every night shift. The resident refused to allow nurse to wrap legs and stated it hurts too (expletive)bad when nurse lifts the resident's legs to wrap. Review of the Resident #203's medication administration record dated July 2021 revealed Resident #203 did not receive any pain medication until 7/11/21 at 2:00 P.M. Interview with Registered Nurse (RN) #705 on 07/20/21 at 3:40 P.M. revealed she spoke to Physician Assistant #1005 about Resident #203's pain and asked for an order for as needed Tylenol as well as an order for Norco. She only received an order for scheduled Norco and completed non-pharmacological interventions for Resident #203's pain, which were effective. She was unable to administer the Norco until 07/11/21 when she received it from the pharmacy, despite the order having been placed on 07/10/21. RN #705 stated it typically only takes a few hours to receive authorization from the pharmacy to pull medication such as Norco from the emergency box and administer it. RN #705 stated she notified PA #1005 on 07/10/21 that the pharmacy needed his signature on the order and he stated he would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 9 of 13 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 07/26/2021 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 sign it as soon as possible. Level of Harm - Minimal harm or potential for actual harm During interview on 07/21/21 at 4:54 P.M., PA #1005 stated he signed the Norco prescription on 07/10/21 and the pharmacy had everything they needed from the facility on 07/10/21. He is unsure as to why it took so long for the pharmacy to allow the nurse to pull Resident #203's from the emergency box and administer it. He typically orders as needed Tylenol if a resident is in pain while staff are awaiting authorization from the pharmacy to pull narcotic pain medications. Residents Affected - Few Interview with Director of Nursing on 07/22/21 at 1:20 P.M. verified staff did not administer Resident #203's pain medication ordered on 07/10/21 until 07/11/21 and Resident #203 refused treatment orders for her legs due to pain associated with the treatments. Review of the facility policy titled Pain-Clinical Protocol, revised March 2018, revealed staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain. The staff will evaluate and report the resident's use of standing and PRN analgesics. Depending on characteristics of pain, the physician may start with PRN doses or supplemental standing doses with PRN doses for breakthrough pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 10 of 13 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 07/26/2021 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to update the daily posted staffing. The affected all 54 residents in the facility. Residents Affected - Many Findings include: During observation on 07/19/21 at 8:00 A.M. on entrance to the facility, the posted nurse staffing on the wall near the front desk was dated for Friday 07/16/21. During interview on 07/19/21 at 8:10 A.M., Business Office Manager (BOM) #406 confirmed the daily posted nurse staffing information was dated for 07/16/21 and had not been updated since Friday morning. BOM #406 stated the nurse on duty on the weekends should update the posted staffing each day. The staffing policy was requested from the Administrator but was not provided for review at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 11 of 13 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 07/26/2021 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 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 record review and staff interview, the facility failed to attempt non-pharmacological interventions before administering an as needed anti-psychotic medication. This affected one (Resident #38) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with a diagnoses including psychosis not due to a substance or know physiological condition, schizoaffective disorder, bipolar type, anemia in chronic kidney disease, vascular dementia with behavioral disturbance, suicidal ideations, major depressive and anxiety disorder. The Minimum Data Set (MDS) assessment, dated 05/03/21, revealed Resident #38 was cognitively impaired. Review of the physician orders dated 07/15/21 revealed Haloperidol (anti-psychotic/anti-manic) tablet, five milligrams (mg), give one tablet by mouth, every eight hours, as needed for agitation. Review of the Medication Administration Record (MAR) on 07/21/21 revealed Resident #38 was administered Haloperidol on 07/14/21, 07/15/21, 07/20/21, 07/21/21 and 07/22/21 with no documented non-pharmacological interventions attempted before administering the medication. During interview on 07/22/21 at 11:30 A.M., the Director of Nursing (DON) stated there were no documentation for non-pharmacological interventions before staff administered an as needed anti-psychotic medication to Resident #38. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 12 of 13 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 07/26/2021 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 staff interview, the facility failed to have labs drawn as ordered. This affected two (Residents #9 and #13) of five residents reviewed for unnecessary medications. The facility census was 54. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #9 had physician orders dated 05/17/20 to have a Digoxin level to be drawn every six months in April and October. Review of the lab work sheet revealed the Digoxin level was drawn on 07/16/21. Interview with the Director of Nursing (DON) on 07/22/21 at 3:00 P.M. revealed the lab was drawn in July instead of April as ordered. 2. Review of the medical record for Resident #13 revealed a physician order dated 05/19/21 for Lipid Panel, Hemoglobin A1C, thyroid stimulating hormone (TSH), comprehensive metabolic panel (CMP), Depakote every 6 months in February and August. Review of the lab documentation dated 05/12/21 revealed the Depakote level was drawn in May and should have been drawn in February. Interview with the DON on 07/22/21 at 4:00 P.M. confirmed the lab draw was three months late being drawn. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 13 of 13