Inspection·August 18, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the maintenance concern logs, interview with resident and interview with the staff, the facility failed to ensure the toilet in the bathroom of Resident #10 and #21 was in good working order. This affected two residents (Resident #10 and #21) of three reviewed for environment. The facility census was 78. Findings included: Review of the medical record for Resident #10 revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including depression, hypotension, osteoporosis, restless leg syndrome. insomnia, diabetes, and inflamed seborrheic keratosis. Review of the quarterly Minimum Data Set assessment for Resident #10, dated 07/17/23, revealed Resident #10 had moderately impaired cognition. Review of the medical record for Resident #21 revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, hemiplegia to the right side, severe protein calorie malnutrition, dysphagia, chronic obstructive pulmonary disease, thyrotoxicosis, transient ischemic attack, major depressive disorder, dementia, delirium anxiety disorder, catatonic schizophrenia, and osteoarthritis. Review of the quarterly Minimum Data Set assessment for Resident #21, dated 05/17/23, revealed Resident #21 had moderately impaired cognition . Review of the maintenance logs revealed on 06/17/23 it was documented on the logs the toilet in Resident #10's and Resident #21's room was messed up, tried to plunge it but it will not go down. Resolution was the toilet was plunged and verified it was working. Review of the plumping company invoice with a service date of 08/01/23 revealed they were at the facility to clear the toilet in Resident #10's and Resident #21's room due to it being backed up. Review of the maintenance logs revealed on 08/02/23 the toilet in Resident #10's and Resident #21's room was plugged and almost overflowing. The resolution was to snake the toilet. Observations on 08/18/23 at 10:10 A.M. and 11:10 A.M. revealed the room for Resident #10 and #21 had a toilet full of feces and it would not flush. There was a toilet riser on the toilet with feces splashed on it. (continued on next page) 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 3 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 08/18/2023 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)