Inspection·December 21, 2023

F 0755 heart disease of coronary artery. The resident was discharged on 11/28/23. Level of Harm - Minimal harm or potential for actual harm Review of November 2023 physician orders for Resident #110 revealed orders for Lipitor 80 mg at bedtime, the antidepressant sertraline 50 mg at bedtime, the medications to treat COPD including Stiolto Respimat inhalation 2.5-2.5 micrograms (mcg/act) two (2) puffs orally twice daily and budesonide-formoterol fumarate inhalation 80-4.5 mcg/act 2 puffs orally twice daily, the nitrate medication isosorbide mononitrate extended release (ER) 30 mg twice daily, and the diuretic metolazone 5 mg twice daily. Residents Affected - Some Review of the November 2023 MAR for Resident #110 revealed on 11/18/23 at bedtime the resident did not receive Lipitor 80 mg, sertraline 50 mg, Stiolto Respimat inhalation, budesonide-formoterol fumarate, isosorbide ER 30 mg, and metolazone 5 mg. Resident #110 also did not receive budesonide-formoterol fumarate in the morning on 11/19/23. 4. Review of the medical record for Resident #111 revealed an admission date of 10/12/23. Diagnoses included sepsis, chronic respiratory failure, type two diabetes, chronic obstructive pulmonary disease, acute kidney failure, depression, heart failure, hypertension, and coronary artery disease. The resident was discharged on 11/20/23. Review of October 2023 physician orders for Resident #111 revealed orders for Lantus solostar insulin 100 units/ml inject 32 units subcutaneously (SQ) at bedtime, the nerve pain medication pregabalin 25 mg daily, the medication to treat COPD fluticasone-salmeterol inhalation 250-50 mcg/act 1 puff twice daily, and the pain medication oxycontin ER abuse deterrent 20 mg every 12 hours until 11/11/23. Review of the October 2023 MAR for Resident #111 revealed on 10/13/23 and 10/14/23 the resident did not receive Lantus solostar 32 units SQ at bedtime. On 10/13/23, Resident #111 did not receive fluticasone-salmeterol at 6:00 A.M. On 10/12/23 at 6:00 P.M. and 10/13/23 at 6:00 A.M., the resident did not receive oxycontin ER abuse deterrent 20 mg. Also, on 10/13/23, the resident did not receive pregabalin 25 mg in the morning. 5. Review of the medical record for Resident #112 revealed an admission date of 11/07/23. Diagnoses included COPD, chronic respiratory failure, type two diabetes, glaucoma, depression, anemia, hypertension, seizures, congestive heart failure, and atherosclerotic heart disease of native coronary artery. The resident was discharged on 12/06/23. Review of November 2023 physician orders for Resident #112 revealed orders for the antihistamine azelastine nasal solution 0.1 percent (%) both nostrils twice daily, the medication to treat COPD budesonide-formoterol fumerate inhalation aerosol 160-4.5 mcg/act 2 puffs twice daily, the medication for glaucoma dorzolamide solution 2% one drop in both eyes twice daily, Farxiga 10 mg daily for diabetes, glucophage 1000 mg twice daily for diabetes, insulin glargine solostar pen 100 units/ml inject 35 units SQ at bedtime, the cholesterol medications fenofibrate 160 mg at bedtime and rosuvastatin 40 mg at bedtime, and venlafaxine ER 75 mg daily for depression. Review of the November 2023 MAR for Resident #112 revealed on 11/07/23 the resident did not receive insulin glargine 35 units SQ, fenofibrate 160 mg, rosuvastatin 40 mg, venlafaxine ER 75 mg, budesonide-formoterol fumerate inhalation, dorzolamid solution 2%, glucophage 1000 mg, and azelastine nasal solution at bedtime. Also, Resident #112 did not receive Farxiga 10 mg in the morning on 11/08/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 12/21/22 at 9:30 A.M. with the Director of Nursing (DON) verified Resident #29, Resident #32, Resident #110, Resident #111, and Resident #112 did not receive medications as ordered, from the examples above, on the evening each resident admitted to the facility. The DON stated she was educating all nurses on pulling medications from the Omnicell (emergency medication back-up system) or notifying the physician to ensure medications can be held and started the next day when the medications were available from the pharmacy. Review of an undated policy titled, Administering Medications, revealed medications must be administered in accordance with the orders, including any required timeframes. This deficiency represents non-compliance investigated under Complaint Number OH00148733. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 3 of 3