Inspection·October 5, 2023

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #69's medical record revealed an admission date of 02/28/23. Diagnoses included severe sepsis with shock, adult failure to thrive, acute kidney failure, and obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was rarely understood. Further review of Resident #69's medical record revealed he was admitted to the hospital on [DATE] with pus in urine, urinary retention, and lethargy. There was no evidence in the medical record that Resident #69 and/or resident representative was provided a bed hold notice upon Resident #69's discharge to the hospital on [DATE]. Interview with Licensed Practical Nurse (LPN) #218 on 10/05/23 at 10:23 A.M. verified there was no bed hold notice given to Resident #69 and/or resident representative when he went to the hospital on [DATE]. 2. Review of Resident #76's medical record revealed an admission date of 06/27/23. Diagnoses included Alzheimer's disease, dementia, and sepsis with severe cognitive impairment. Further review of the medical record revealed Resident #76 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. There was no evidence in the medical record that Resident #76's representative was provided a bed hold notice upon Resident #76's discharge to the hospital on [DATE]. Interview on 10/04/23 at 1:56 P.M. with Resident #76's representative revealed she was at the facility visiting the Resident #76 when he was sent to the hospital, and she was given papers to deliver to the hospital staff. She denied receiving a copy of the written bed hold notification letter when he went to the hospital. She confirmed she had not received a bed hold notification letter while he was in the hospital on [DATE]. Interview on 10/04/23 at 2:20 P.M. with the Regional Clinical #500 confirmed there was no documentation Resident #76's representative received a written copy of a bed hold policy for Resident #76's admission to the hospital on [DATE]. 4. Review of Resident #18's medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included sepsis, adult failure to thrive, and dementia. Further review of the medical record revealed Resident #18 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. There was no evidence that Resident #18 or the resident representative was given a bed hold notice when discharged to the hospital on [DATE]. Interview on 10/05/23 at 10:23 A.M. with Licensed Practical Nurse Manager (LPN) #218 confirmed there was no evidence or documentation that the resident or resident representative received a bed hold notification when discharged to the hospital on [DATE]. Review of the facility's undated Bed-Holds and Returns Policy revealed prior to a transfer, written information will be given to the residents and the resident's representatives that explains in detail which included the rights and limitations of the resident regarding bed-holds, the facility per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 2 of 7 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 10/05/2023 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)

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Some diem rate required to hold a bed (non-Medicaid) , or to hold a bed beyond the state bed-hold period (Medicaid residents). Based on medical record review, resident and staff interviews, resident representative interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the bed hold policy upon the residents' discharge to the hospital. This affected four (Residents #16, #18, #69, and #76) of four residents reviewed for bed hold notification. The facility census was 76. Findings include: 1. Review of Resident #16's medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included non-alcoholic steatohepatitis, irritable bowel syndrome without diarrhea, pancytopenia, sepsis, hepatic encephalopathy, cirrhosis of liver, chronic kidney disease, and acute kidney failure. Review of the medical record revealed Resident #16 was discharged to the hospital on [DATE]. There was no evidence in the medical record that Resident #16 and/or resident representative was provided a bed hold notice upon Resident #16's discharge to the hospital on [DATE] from 08/26/23 to 10/02/23. Interview on 10/03/23 at 3:48 P.M. with Clinical Operation Specialist #501 revealed a blank form of the resident bed hold letter was provided at this time as an example of what was provided to a resident on a transfer to the hospital. Clinical Operation Specialist #501 stated a bed hold letter was provided to the residents upon discharge to the hospital, but a signed copy was not kept. Interview on 10/03/23 03:57 P.M. with Resident #16 stated the bed hold letter was not received upon transfer to the hospital on [DATE]. Interview on 10/03/23 at 4:02 P.M. with Licensed Practical Nurse (LPN) #215 revealed the bed hold letter for Resident #16 was given to the emergency medical team (EMT) for the hospital, and a copy of the bed hold letter was not kept. LPN #215 confirmed the charting on the bed hold notification for 08/26/23 was completed on 10/03/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 3 of 7 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 10/05/2023 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete an accurate Pre-admission Screen and Resident Review (PASARR) for Resident #62. This affected one (Resident #62) of two residents reviewed for PASARR. The facility census was 76. Residents Affected - Few Findings include: Review of Resident #62's medical record revealed an admission date of 03/14/23. Diagnoses included catatonic schizophrenia (diagnosis upon admission on [DATE]), major depressive disorder, psychosis, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired. Review of Resident #62's PASARR dated 06/20/23 revealed the PASARR had only mood disorder marked as a serious mental disorder. The PASARR did not include Resident #62's diagnosis of catanoic schizophrenia, which Resident #62 had the diagnosis since admission on [DATE]. Interview with Certified Operations Specialist #249 on 10/03/23 at 3:35 P.M. verified Resident #62 had a catatonic schizophrenia diagnosis and it was not coded on the PASARR dated 06/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 4 of 7 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 10/05/2023 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)

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 resident and staff interview, and record review, the facility failed to allow the participation of the resident and/or resident representative in the comprehensive care plan when there was no evidence a care plan conference was conducted. This affected two (Resident #47 and #68) of two residents reviewed for care plan conferences. The facility census was 76. Findings include: 1. Record review for Resident #47 revealed an admission date of 11/05/22. Diagnoses included malignant neoplasm of larynx, chronic obstructive pulmonary disease, stenosis of larynx, acute tracheitis without obstruction, malignant neoplasm of laryngeal cartilage, shortness or breath, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact. Further review of the medical record revealed there was no evidence of care planning conferences from 11/05/22 to 10/02/23. Interview with Resident #47 on 10/02/23 at 10:45 A.M. revealed he has never had a care plan meeting. Interview with Regional Quality Assurance #500 on 10/05/23 at 1:40 P.M. verified there was no care planning conferences for Resident #47. 2. Review of Resident #68's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia, psychotic disturbances, mood psychotic disturbances, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had no cognitive impairment. Further review of the medical record for Resident #68 from 03/26/23 to 10/02/23 revealed there were no care conferences held for Resident #68 Interview on 10/03/23 at 4:10 P.M. with Administrator Assistant #504 confirmed she was unable to find any documentation of Resident #68 and her representative being invited to a care conference or having a care conference for Resident #68. Interview on 10/04/23 at 9:10 A.M. with Regional Quality Assurance Specialist #500 confirmed Resident #68 did not have a care conference since admitted to the facility on [DATE]. The Regional Quality Assurance Specialist #500 confirmed the facility does not have a Care Conference Policy and Procedure for review. Review of the facility's Care Conference Invitation revealed care conferences are held for all of the residents 72 hours upon admission, quarterly, annually, or more frequently if there is a major change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 5 of 7 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 10/05/2023 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)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on medical record review, staff interview, and review of the hospice contract, the facility failed to ensure hospice services were provided and documentation of the services and care provided to a resident receiving hospice services were available at the facility. This affected one (Resident #15) of two residents reviewed for hospice services. The facility census was 76. Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/11/22. Diagnoses included dementia, psychotic disturbances, and anxiety. Resident #15 was severely cognitively impaired and had been on hospice services since 04/19/22 for cerebral atherosclerosis. Review of Resident #15's hospice care binder visit notes from 08/10/23 to 10/05/23 revealed no documentation from nursing, home health aide, social worker, or chaplain that the visited Resident #15 and there was no documentation of the visit notes with the care and services provided to Resident #15. Review of Resident #15's Hospice Comprehensive Assessment and Plan of Care from 08/12/23 to 10/10/23 revealed Resident #15 was to have skilled nursing visits two times a week up to four times a week as needed, home health aide two times a week, medical social worker once a month and as needed, home health aide two times a week and chaplain one time a month and as needed. Interview on 10/05/23 at 8:30 A.M. with Clinical Operation Specialist #502 confirmed she has no documentation for hospice services between 08/10/23 to 10/05/23. Review of the Hospice services contract between the facility and Hospice signed on 03/25/29 Section : Manner of Communication revealed all communications between Hospice and Nursing Facility pertaining to the care and services provided to the Resident Patient shall be documented in the Resident Patient's clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 6 of 7 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 10/05/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, and policy review, the facility failed to follow appropriate infection control techniques when they failed to cleanse their hands after changing gloves and failed to appropriately clean a wound for Resident #64. This affected one (Resident #64) of three residents reviewed for skin conditions The facility census was 76. Residents Affected - Few Findings include: Record review of Resident #64 revealed an admission date of 12/14/22. Diagnoses included rectal fistula, quadriplegia, pressure ulcer of sacral region stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Review of Resident #64's physician order dated 10/04/23 revealed an order for treatment to the coccyx wound to cleanse the area with wound cleanser, pat dry, apply collagen to wound base, pack with Dakin's soaked gauze, and cover with foam dressing every shift and as needed. Observation on 10/04/23 at 11:25 A.M. revealed Licensed Practical Nurse (LPN) #282 gathered supplies including collagen, wound cleanser, Dakin's, gauze, and foam dressing to change Resident #64's coccyx wound dressing. LPN #282 sanitized hands and put on clean gloves then she removed the soiled dressing dated 10/04/23 from night shift. She then removed her gloves and did not wash or sanitize her hands and put on clean gloves. LPN #282 used the wound spray and sprayed approximately 10-12 inches from the wound and went around the outside of the wound with gauze. She did not clean inside the wound and the wound cleanser barely reached the wound from the distance she sprayed it. LPN #282 did not change gloves after she cleaned the wound. LPN #282 packed the wound with collagen then wet gauze with quarter strength Dakin's, and dry gauze. She then put on the foam dressing and dated it. Interview with LPN #282 on 10/04/23 at 11:53 A.M. verified she did not wash her hands or sanitize them after removing gloves or after cleaning the wound area. LPN #282 also verified she did not clean the wound area thoroughly and sprayed the wound cleanser from 10 inches away. Review of a facility handwashing hand hygiene policy dated 08/01/19 revealed use an alcohol based hand rub containing at least 62% alcohol, or soap and water for the following situations: after removing gloves. Review of a facility dry clean dressings policy dated 09/01/13 revealed clean the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area usually from the center outward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365684 If continuation sheet Page 7 of 7