Inspection·February 27, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 07/23/23 revealed a general note stated the resident informed nurse of unsupervised smoking going on. When nurse stated she would check on it, the resident became irate and lifted his hand as if he were to smack the nurse. Review of the progress note dated 11/13/23 revealed a report was made to social services that the resident was showing signs of aggression with another resident. When asked, Resident #55 denied this. Review of the progress note on 01/08/24 revealed a behavior note from the Administrator where the Administrator spoke with Resident #55 about how he treats other residents and staff due to complaints of being nasty to them cussing at staff and using sexual remarks when assisting with showers. The resident was informed of the possibility of getting a 30-day notice and also offered to send him to a homeless shelter and stated behaviors must stop. Interview on 02/27/24 at 10:40 A.M. with the Administrator revealed Resident #55 and Resident #75 were upset with how the Administrator handled a situation about a discussion related to resident discharge. The Administrator revealed he threatened to discharge Resident #55 due to his nastiness toward staff. The Administrator revealed he told Resident #55 if behaviors didn't stop, the resident would be discharged to the homeless shelters. The Administrator revealed the resident bullied other residents on the smoking patio and revealed he had a behavioral care plan. The Administrator revealed Resident #75 and her family were upset about the comment and threat of discharge to a shelter and requested for supervisor contact information. Resident #75's family contacted Corporate Administrator (CA) #250 to discuss her concerns and afterwards, CA #250 reached out to the Administrator and offered assistance. The Administrator revealed he informed Resident #75's family he knew he was not allowed to discharge Resident #55 to a homeless shelter and confirmed he was threatening him in an attempt to scare him straight. The Administrator revealed he was trying to scare him to not be a bully. Interview on 02/27/24 at 11:10 A.M. with Resident #75's family revealed the Administrator informed her he could not actually discharge Resident #55 to a shelter but wanted to scare him straight. Resident #75's family reported the Administrator's behavior and comments were inappropriate. Interview on 02/27/24 at 1:13 P.M. and again at 2:48 P.M. with Resident #55 confirmed he met with the Administrator and was told he would be dropped off at the homeless shelter. Resident #55 revealed he felt the threat of discharge was serious and reported he was trying to discharge to a different facility. Interview on 02/27/24 at 1:25 P.M. with Licensed Practical Nurse (LPN) #210 revealed she had not heard of Resident #55 having behaviors and revealed behavioral tracking was not being done for Resident #55. She revealed Resident #55 could be very direct and loud at times. LPN #210 reported any behaviors or threatening comments should be documented in the medical record. Interview on 02/27/24 at 1:35 P.M. with Resident #75 revealed after Resident #55 had a conversation with the Administrator, Resident #55 came to Resident #75's room tearful and revealed he was upset and told Resident #75 he was being kicked out to a shelter. Interview on 02/27/24 at 2:24 P.M. with the Director of Nursing (DON) revealed she was unable to find evidence of any recent behaviors which would lead to a discussion related to discharge and giving a 30 day discharge notice. (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 02/27/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/27/24 at 2:36 P.M. with CA #250 revealed a resident's family (Resident #75) contacted him related to concerns relating to the Administrator threatening a resident to discharge. CA #250 revealed he apologized from a customer service standpoint and spoke with the Administrator and offered assistance if needed. Interview on 02/27/24 at 3:20 P.M. with the Administrator confirmed the facility had only one incident documented since 07/20/23 related to Resident #55's behaviors. This deficiency represents non-compliance investigated under Complaint Number OH00150051. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 3 of 3