Inspection·July 27, 2023

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not receive any notifications from 12/31/23 to 07/24/23, that the amount in Resident #16's account was over the social security income resource limit and Resident #16 may lose eligibility for Medicaid or social security income. BOM #32 confirmed Resident #16 received Medicaid benefits and was over the income limit. 2. Review of the Resident #40's medical record revealed an admission date of 01/27/20, with diagnoses including: cerebral infarction, type two diabetes mellitus, heart failure, anxiety disorder, congenital deformity of the fingers and hand, hypothyroidism, and moderate protein calorie malnutrition. Review of Resident #40's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #40 required extensive assistance with bed mobility, eating and personal hygiene. Resident #40 also required supervision with eating and total dependence with transfers. Review of Resident #40's census documentation dated 07/25/23 revealed Resident #40's payer source was Medicaid. Review of Resident #40's quarterly statement from 12/31/22 to 03/31/23 revealed Resident #40 had an ending balance of $9170.19 on 03/31/23. Review of Resident #40's quarterly statement from 04/01/23 to 06/30/23 revealed Resident #40 had an ending balance of $9370.93 on 06/30/23. Review of Resident #40's notifications that the amount in Resident #40's account was over the social security income resource limit and Resident #40 may lose eligibility for Medicaid or social security income from 12/31/23 to 07/09/23 revealed Resident #40 did not receive any notices until 07/10/23. Review of Resident #40's phone notification dated 07/10/23 revealed the facility spoke with Resident #40's family regarding the access money in Resident #40's account on 07/10/23. The notice did not contain any information that Resident #40 may lose eligibility for Medicaid or social security income. Interview on 07/25/23 at 3:21 P.M., with BOM #32 verified Resident #40 did not receive any notifications from 12/31/23 to 07/09/23 that the amount in Resident #40's account was over the social security income resource limit and Resident #40 may lose eligibility for Medicaid or social security income. BOM #32 confirmed Resident #40 received Medicaid benefits and was over the income limit. Review of the policy titled Resident Funds dated 2020 revealed the facility will notify each resident that receives Medicaid benefits when the amount in the resident's account reaches 200 dollars less than the social security income resource limit for one person. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 2 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to have accurate advance directives in the electronic and medical record. This affected two (#70 and #71) of four residents reviewed for advanced directives. The facility census was 105. Findings include: 1. Review of Resident #70's medical record revealed an admission date of 06/15/23, with diagnoses of fracture of humerus right arm, chronic obstructive pulmonary disease, hypotension, atherosclerotic heart disease of native coronary artery, heart failure, and atrial fibrillation. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with personal hygiene, toilet use, dressing, transfer, and bed mobility. The Resident uses a walker to aid in mobility and is frequently incontinent. Review of Resident #70's paper medical record on 07/25/23 at 11:04 A.M., revealed the resident had a do not resuscitate comfort care (DNR-CC) form in the paper medical record dated 06/19/23. Review of Electronic medical record on 07/25/23 at 2:20 P.M., revealed an active order for Full Code for cardiopulmonary resuscitation dated 06/16/23. Interview on 07/25/23 at 2:22 P.M., with Licensed Practical Nurse (LPN) #66 verified the electronic record showed the resident was a full code and the paper chart code status was DNR-CC and they did not match. 2. Review of the medical record for the Resident #71 revealed an admission date of 04/12/22 with diagnoses including: diabetes type two, embolism, malnutrition, myalgia, dysphagia, depression, and neuromuscular dysfunction. Review of the care plan dated 04/15/22 revealed resident wished to have code status of Do Not Resuscitate -Comfort Care (DNR-CC). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively impaired and required extensive assistance of one staff for bed mobility and total dependence of two staff. Review of the electronic medical record revealed the resident had a code status of DNR-CC. Review of the paper medical record had a physician signed code status dated 04/13/22 of DNRCC-A (comfort care arrest). Review of policy titled, Advanced Directives, dated 08/2022, revealed information about whether or not the resident had executed an advanced directive shall be displayed prominently in the medical record. The care plan should be consistent with documented treatment preferences and/or advanced directives. Changes of the directive must be submitted, and the medical team must be updated so changes can be made in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 3 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, fall alarm list review, incident report review, and staff interview, the facility failed to ensure a resident was assessed to utilize a position change alarm (pull-tab alarm). This affected one (#86) of seven residents reviewed for falls. The facility identified three residents with pull-tab fall alarms in the facility. The facility census was 105. Residents Affected - Few Findings include: Review of the Resident #86's medical record revealed admitted to than admission date of 05/25/23, with diagnoses including: hypertensive heart disease with heart failure, atrial fibrillation, chronic kidney disease stage three, osteoarthritis, muscle weakness, and hyperlipidemia. Review of Resident #86's admission assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #86 required supervision with eating and had fallen in the last month prior to admission. Review of Resident #86's fall assessment dated [DATE] revealed Resident #86 was at moderate risk for falls. Review of Resident #86's fall assessment dated [DATE] revealed Resident #86 was at high risk for falls. Review of Resident #86's fall care plan dated 06/12/23 revealed Resident #86 had a potential for falls related to cognitive impairment and does not recognize her own limitations. Interventions included assist resident on and off the toilet, monitor resident for increased agitation and redirect resident with activities of choice. Resident #86's fall care plan did not include any information related to fall or pull-tab alarms (position change alarm). Review of Resident #86's care plans dated 07/25/23 revealed Resident #86 did not have a care plan for a pull-tab alarm on her wheelchair. Review of Resident #86's physician orders on 07/25/23 revealed Resident #86 did not have an order for a pull-tab alarm on her wheelchair. Review of Resident #86's assessments on 07/25/23 revealed Resident #86 did not have a restraint assessment for a pull-tab alarm on her wheelchair. Review of Resident #86's progress notes from 05/25/23 to 07/25/23 revealed Resident #86 did not any documentation regarding her pull-tab alarm on her wheelchair. Review of Resident #86's progress note dated 07/21/23 at 3:29 P.M., revealed staff were charting at the nurse's station around 2:55 P.M. Staff turned to asked staff to complete a shower sheet and Resident #86 fell out of the wheelchair. Staff responded immediately and Resident #86 was noted with a large hematoma on her left forehead and temporal area. Resident #86 was placed in bed and fully assessed and had bruising to her left wrist. Resident #86's family arrived after the fall and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 4 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0604 notified in person and Resident #86's physician was notified and Resident #86 was sent to the hospital. Level of Harm - Minimal harm or potential for actual harm Review of Resident #86's progress note dated 07/21/23 at 10:32 P.M., revealed Resident #86 returned from the hospital with medium sized hard hematoma to the left side of her forehead. The area with purple in color with no open areas. A new order for Norco 5-325 milligrams (mgs) every six hours as needed was ordered. Resident #86 had a closed fracture of the superior ramus of left pubis with no surgery or other instructions noted. Residents Affected - Few Review of Resident #86's incident report dated 07/21/23 revealed Resident #86 was sitting in her wheelchair in the front lobby as she usually does after returning from lunch. Resident #86 had proper footwear on and was last seen five minutes prior to the fall sitting in the wheelchair. At 2:55 P.M., the resident was lying on the floor in front of the wheelchair and Resident #86 had a large hematoma on her left forehead. Resident #86 was placed in bed for further assessment and complained of pain in the left shoulder and was sent out to the emergency department for evaluation. Resident #86's son had just arrived and was aware of the fall and accompanied Resident #86 to the emergency department. Resident #86 returned to the facility with a new order for pain medication due to a fracture of the left superior ramus. The nurse applied a chair alarm to the resident upon return to the hospital. Observation of Resident #86 on 07/24/23 at 10:06 A.M., revealed Resident #86 was sitting in her wheelchair and Resident #86 had a pull-tab alarm on her wheelchair that was connected to the back of her shirt. Interview on 07/26/23 at 11:13 A.M., with Registered Nurse (RN) #30 verified Resident #86 did not have a physician order for a pull-tab alarm, or a restraint assessment for the pull-tab alarm prior to 07/26/23. RN #30 stated Resident #86's pull-tab alarm was put in place after Resident #86's 07/21/23 fall. Review of the facility's list of fall alarms dated 06/27/23 revealed three residents in the facility had pull-tab alarms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 5 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to develop resident care plans for anticoagulant medication use, oxygen use, and psychotropic medication use. This affected three (#51, #60, and #73) resident of 22 residents reviewed for care plans. The facility census was 105. Findings include: 1. Review of the Resident 51's medical record revealed an admission date of 09/03/20, with diagnoses including: transient cerebral ischemic attack, type two diabetes mellitus with hyperglycemia, diarrhea, schizoaffective disorder, and major depressive disorder. Review of Resident #51's quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #51 was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #51 required supervision with eating and received anticoagulant medication during the review period. Review of Resident #51's physician orders dated 09/24/23 revealed Resident #51 was ordered pradaxa capsule 75 milligrams (mgs) give one capsule by mouth two times a day for clot prevention and cerebrovascular accident (CVA). Review of Resident #51's care plans dated 07/25/23 revealed Resident #51 did not have a care plan for anticoagulant medication or to monitor bruising and bleeding. Interview on 07/25/23 at 3:06 P.M., with Licensed Practical Nurse (LPN) #79 verified Resident #51 did not have a care plan for anticoagulant medication or to monitor bruising and bleeding. LPN #79 stated Resident #51's was prescribed an anticoagulant medication. 2. Review of the Resident 73's medical record revealed an admission date of 01/18/23, with diagnoses including: chronic obstructive pulmonary disease with exacerbation, acute chronic congestive heart failure, moderate protein calorie malnutrition, difficulty in walking, gout, atrial fibrillation, and hyperlipidemia. Review of Resident #73's quarterly MDS assessment dated [DATE] revealed Resident #73 was moderate cognitively impaired and required limited assistance with bed mobility, transfers, and dressing. Resident #73 required supervision with eating; extensive assistance with toileting and personal hygiene; and was on oxygen. Review of Resident #73's physician orders dated 01/19/23 revealed Resident #73 was ordered oxygen at one to two liters by nasal cannula every day and night shift. Review of Resident #73's care plans dated 07/25/23 revealed Resident #73 did not have a care plan for oxygen use. Interview on 07/25/23 at 3:06 P.M., with LPN #79 verified Resident #73 did not have a care plan for oxygen use. LPN #79 stated Resident #73's was prescribed oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 6 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the Resident 60's medical record revealed an admission date of 06/02/20, with diagnoses including: chronic obstructive pulmonary disease, atrial fibrillation, acute kidney failure, hypotension, anxiety disorder, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #60's quarterly MDS assessment dated [DATE] revealed Resident #60 severely cognitively impaired and required extensive assistance with bed mobility, transfers, toileting, personal hygiene, and dressing. Resident #60 required supervision with eating and extensive assistance with toileting and personal hygiene. Review of Resident #60's physician order dated 06/03/20 revealed Resident #60 was ordered pradaxa capsule 75 milligrams (mgs) give one capsule by mouth two times a day for atrial fibrillation. Review of Resident #60's physician order dated 06/20/23 revealed Resident #60 was ordered seroquel 50 milligrams (mgs) give one tablet by mouth at bedtime for schizophrenia. Review of Resident #60's care plan dated 07/25/23 revealed Resident #60 did not have a care plan for psychotropic medication use, anticoagulant medication or to monitor bruising and bleeding. Interview on 07/25/23 at 3:06 P.M., with LPN #79 verified Resident #60 did not have a care plan for anticoagulant medication or to monitor bruising and bleeding. LPN #79 stated Resident #60's was prescribed an anticoagulant. LPN #79 also verified Resident #60 was ordered Seroquel and did not have a care plan for psychotropic medications or Seroquel use. Review of the policy titled, Care Plans, Comprehensive Person Centered dated 03/16/23 revealed the facility should create care plans that include measurable objectives and timeframe's to meet resident's needs. Facility shall develop a person-centered care plan for each resident with interventions derived from a thorough analysis of the information gathered as part of the care plan. Care plan interventions are chosen after gathering data, proper sequencing of events, careful consideration of the problems and causes and relevant clinical decision making. Assessments and interventions were revised as information changes. The policy revealed the care plan shall be reviewed and updated after a significant change in resident condition, when the desired outcomes were not met, after a readmission from a hospitalization and at least quarterly in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 7 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 observation, record review, policy review, and staff interview, the facility failed to ensure a resident's fall care plan was updated to include new fall interventions. This affected two (#86 and #66) of 22 residents reviewed for care plans. The facility census was 105. Findings include: Review of the Resident #86's medical record revealed admitted to than admission date of 05/25/23, with diagnoses including: hypertensive heart disease with heart failure, atrial fibrillation, chronic kidney disease stage three, osteoarthritis, muscle weakness, and hyperlipidemia. Review of Resident #86's admission assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #86 required supervision with eating and had fallen in the last month prior to admission. Review of Resident #86's fall assessment dated [DATE] revealed Resident #86 was at moderate risk for falls. Review of Resident #86's fall assessment dated [DATE] revealed Resident #86 was at high risk for falls. Review of Resident #86's fall care plan dated 06/12/23 revealed Resident #86 had a potential for falls related to cognitive impairment and does not recognize her own limitations. Interventions included assist resident on and off the toilet, monitor resident for increased agitation and redirect resident with activities of choice. Resident #86's fall care plan did not include any information related to fall or pull-tab alarms (position change alarm). Review of Resident #86's care plans dated 07/25/23 revealed Resident #86 did not have a care plan for a pull-tab alarm on her wheelchair. Review of Resident #86's physician orders on 07/25/23 revealed Resident #86 did not have an order for a pull-tab alarm on her wheelchair. Review of Resident #86's assessments on 07/25/23 revealed Resident #86 did not have a restraint assessment for a pull-tab alarm on her wheelchair. Review of Resident #86's progress notes from 05/25/23 to 07/25/23 revealed Resident #86 did not any documentation regarding her pull-tab alarm on her wheelchair. Review of Resident #86's incident report dated 07/21/23 revealed Resident #86 was sitting in her wheelchair in the front lobby as she usually does after returning from lunch. Resident #86 had proper footwear on and was last seen five minutes prior to the fall sitting in the wheelchair. At 2:55 P.M., the resident was lying on the floor in front of the wheelchair and Resident #86 had a large hematoma on her left forehead. Resident #86 was placed in bed for further assessment and complained of pain in the left shoulder and was sent out to the emergency department for evaluation. Resident #86's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 8 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 son had just arrived and was aware of the fall and accompanied Resident #86 to the emergency department. Resident #86 returned to the facility with a new order for pain medication due to a fracture of the left superior ramus. The nurse applied a chair alarm to the resident upon return to the hospital. Observation of Resident #86 on 07/24/23 at 10:06 A.M., revealed Resident #86 was sitting in her wheelchair and had a pull-tab alarm on her wheelchair that was connected to the back of her shirt. Interview on 07/26/23 at 11:13 A.M., with Registered Nurse (RN) #30 verified Resident #86 did not have a care plan for a pull-tab alarm. RN #30 stated Resident #86's pull tab-alarm was put in place after Resident #86's 07/21/23 fall. 2. Review of Resident #66's medical record revealed an admission date of 04/25/23, with diagnoses including: Parkinson's disease, protein calorie malnutrition, muscle weakness, and repeated falls. Review of the MDS assessment dated [DATE] revealed Resident #66 was cognitively intact and required limited assistance with one staff person physical assist for transfers. Review of the progress notes dated 06/19/23 revealed the resident was found after fall on ground with legs stretched out in front of her and the walker tipped sideways. Resident #66 stated she thought her legs gave out on her. Resident #66 educated to use wheeled walker seat to sit down as needed. Review of fall investigation dated 06/19/23 revealed the resident had a fall on 06/19/23. The intervention listed included staff to use wheeled walker seat to sit down as needed for rest periods when ambulating. Review of the care plans dated 07/25/23 revealed Resident #66 was at risk of falls with interventions for non-slip socks, keep call light in reach, education to not assist with care for her spouse, education to call for staff assistance prior to care and education for resident to use seat of wheeled walker to sit for needed breaks. Interview on 07/26/23 at 4:37 P.M., with Registered Nurse Manager (RNM) #161 confirmed intervention for education to use wheeled walker seat for breaks was not placed on the care plan until 07/25/23 (during the survey). Review of the policy titled, Care Plans, Comprehensive Person Centered dated 03/16/23 revealed the facility should create care plans that include measurable objectives and timeframe's to meet resident's needs. Facility shall develop a person-centered care plan for each resident with interventions derived from a thorough analysis of the information gathered as part of the care plan. Care plan interventions are chosen after gathering data, proper sequencing of events, careful consideration of the problems and causes and relevant clinical decision making. Assessments and interventions were revised as information changes. The policy revealed the care plan shall be reviewed and updated after a significant change in resident condition, when the desired outcomes were not met, after a readmission from a hospitalization and at least quarterly in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 9 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a physician's response to a pharmacy recommendation was followed. This affected one (#52) of five residents reviewed for unnecessary medications. The facility census was 105. Findings include: Review of the Resident #52's medical record revealed an admission date of 03/18/17, with diagnoses including: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, depression, dysphagia, aphasia following cerebral infarction, cerebral infarction, anemia, anxiety disorder, unspecified convulsions, and mixed hyperlipidemia. Review of Resident #52's quarterly minimum data set assessment dated [DATE] revealed Resident #52 was severely cognitively impaired and was prescribed insulin, antianxiety medication, antidepressant medication, and opioids. Review of Resident #52's medication regimen review dated 10/17/22 revealed medications for seizures. Resident #52 was being monitored routinely for seizure activity but there were no lab orders to monitor therapeutic blood levels of those medications with establishing monitoring parameters. The medication regimen review revealed the physician should consider adding lab orders to monitor blood levels for seizure medications. The physician responded on 10/24/22 and documented on the review that the physician agreed with the recommendation and Keppra levels were ordered to be drawn on 10/24/22 and every six months. Review of Resident #52's labs from 10/24/22 from to 07/25/23 revealed no Keppra labs were ordered or drawn. Interview on 07/26/23 at 2:01 P.M. with Registered Nurse (RN) Manager #161 verified Resident #52's physician recommended a Keppra level drawn on 10/24/22 and every six months. RN Manager #161 confirmed Resident #52 did not have a Keppra level drawn from 10/24/22 to 07/25/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 10 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and record review, the facility failed to follow the facility menu and spreadsheets for residents with altered textured diets. This affected 24 (#1, #2, #3, #7, #11, #16, #26, #30, #35, #40, #50, #52, #59, #62, #64, #67, #70, #71, #73, #76, #87, #89, #210 and #204) of 24 residents with orders for pureed and mechanical soft diets. Facility census was 105. Findings include: Review of the facility menu for dated 07/26/23 revealed facility was serving turkey club sandwiches, a balsamic tomato cucumber salad, chips, and pineapple tidbits. Review of the menu spreadsheets for mechanical soft diets dated 07/26/23 revealed the lunch meal included ground turkey sandwich with shredded lettuce and diced tomatoes, diced tomatoes in place of the salad, ranch pasta salad in place of the chips and crushed pineapple. Review of the menu spreadsheets for pureed diets dated 07/26/23 revealed the lunch meal included a turkey sandwich with lettuce, tomatoes, and cheese that was made into a pureed texture with 2 scoops, pureed tomatoes in place of the salad, pureed ranch pasta salad in place of the chips and pureed peaches in place of pineapple tidbits. Review of the diet list provided by the facility revealed 24 (#1, #2, #3, #7, #11, #16, #26, #30, #35, #40, #50, #52, #59, #62, #64, #67, #70, #71, #73, #76, #87, #89, #210 and #204) residents with orders for pureed and mechanical soft diets. Interview and observation on 07/26/23 at 9:51 A.M., with [NAME] #119 revealed the menu this day was turkey club sandwiches with turkey, lettuce, tomato, cheese and bacon, a cucumber and tomato salad and a bag of chips. [NAME] #119 began making the mechanical soft meal by placing baked ham and cheese in a roboku blender once it was chopped, it was mixed by hand with mayonnaise. Then the pureed food was made by placing baked ham in the roboku blender along with bread and chicken stock. [NAME] #119 revealed the mechanical ham would be placed on a bun and the pureed would be scooped on a plate. Then [NAME] #119 made pureed vegetables with a California blend which included carrots, broccoli, and cauliflower along with bread and chicken stock. [NAME] #119 also reported pureed residents would get mash potatoes and mechanical soft would get a V8 juice in place of their vegetables. [NAME] #119 and Dietary Director #101 revealed facility had recipes for their meals. Interview on 07/26/23 at 11:40 A.M., with Dietary Director (DD) #101 and Dietary Manager (DM) #102 confirmed the menu was for a turkey club sandwich which included cheese, bacon, lettuce, and tomato. DD #101 and DM #102 confirmed what was made for the pureed and mechanical soft residents did not include the ingredients listed in the menu and spreadsheets. Confirmed they made ham and not turkey, and the mixture did not include the sandwich toppings. They also confirmed the vegetable (tomato and cucumber salad) was not made according to the menu or spreadsheets. Observation on 07/26/23 at 12:00 P.M. to 12:20 P.M., revealed during the observation of tray line, in addition to the turkey club being different than the menu and spreadsheets, the residents with mechanical soft diets received a V8 juice instead of the diced tomatoes and did not receive ranch pasta salad. Residents with pureed diet orders received California blend vegetables, mashed potatoes, and applesauce. Resident with pureed diets did not receive pureed tomatoes, pureed pasta salad, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 11 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0803 pureed peaches. Level of Harm - Minimal harm or potential for actual harm Interview on 07/26/23 at 3:40 P.M., with Dietician #100 confirmed the kitchen did not serve the items on the menu or follow the spreadsheet for residents with altered textured diets. Dietician #100 revealed he had not made the spread sheets as he was newer to the facility but confirmed no knowledge of making a change to the menu for this select group of diets. Dietician #100 revealed mechanical soft residents can have vegetables and did not need to drink a V8 juice. Dietician #100 revealed he did not think the facility had a policy related to following a menu or spreadsheet. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 12 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review, facility failed to ensure facility made pureed food in a way to keep nutritive values. This affected three (#1, #40 and #67) of three residents with orders for pureed diets. Facility census was 105. Residents Affected - Few Findings include: Review of the facility menu for dated 07/26/23 revealed facility was serving turkey club sandwiches, a balsamic tomato cucumber salad, chips, and pineapple tidbits. Review of the menu spreadsheets for mechanical soft diets dated 07/26/23 revealed the lunch meal included ground turkey sandwich with shredded lettuce and diced tomatoes, diced tomatoes in place of the salad, ranch pasta salad in place of the chips and crushed pineapple. Review of the menu spreadsheets for pureed diets dated 07/26/23 revealed the lunch meal included a turkey sandwich with lettuce, tomatoes, and cheese that was made into a pureed texture with 2 scoops, pureed tomatoes in place of the salad, pureed ranch pasta salad in place of the chips and pureed peaches in place of pineapple tidbits. Review of the recipe for the turkey club sandwiches revealed instructions to puree turkey, mayonnaise, bread, and vegetables together. Facility shall count or measure out the number of portions as needed, process to a smooth consistency and thickener as needed and blend thoroughly. Review of the recipe for the balsamic cucumber and tomato salad revealed instructions to measure the amount of salad mixture needed for the number of puree diets being served, process to a smooth pudding consistency and add thickener as needed. For the mechanical soft diet, it breaks the options down to if resident was allowed some raw vegetables and if not allowed any raw vegetables and instructs to follow the extension sheet and chop finely. Review of the facility list of resident diets revealed three (#1, #40 and #67) residents with orders for pureed diets. Interview and observation on 07/26/23 at 9:51 A.M., with [NAME] #119 revealed he remove [NAME] from chunks of baked ham and added an unmeasured amount of ham and unmeasured amount of cheese was chopped in the roboku blender. An unmeasured amount of mayo was added three plops to the mixture to get it sticky so it stayed on the sandwich. Interview on 07/26/23 at 10:00 A.M., with Dietary Director #101 confirmed residents with regular diets were going to receive turkey clubs and confirmed the altered textured diets were betting baked ham. The turkey sandwiches would include lettuce, tomato, cheese, bacon, and residents would get mayonnaise and mustard packets. Interview and observation on 07/26/23 at 10:02 A.M., with [NAME] #119 revealed an unmeasured amount of baked ham chunks were placed in the roboku blender along with five pieces of bread and an unmeasured amount of chicken broth. [NAME] #119 report he estimates he pour in about one to 1.5 cups of broth. The mixture was blended, and one piece of bread was added, and another unmeasured amount of broth was poured into the blender (estimated 1/2 cup). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 13 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 07/26/23 at 10:13 A.M., with Dietary Director (DD) #101 and [NAME] #119 revealed the mixture was to the correct pureed texture and ready to be kept in warmer until service time. DD#101, [NAME] #119 and surveyor tasted the meat mixture. DD #101 and [NAME] #119 confirmed the food blend had small pieces of food chunks of ham and tasted salty. [NAME] #119 put the mixture back in blender added a few unmeasured amounts of broth (estimated a two tablespoons) and blended for several minutes. After tasting again [NAME] #119 and DD #101 confirmed mixture still had some graininess. Observation and interview on 07/26/23 at 10:25 A.M., revealed [NAME] #119 made a capri blend vegetable mix containing carrots, broccoli, and cauliflower. An unmeasured number of vegetables was added to the roboku blender, and four pieces of bread was added along with an unmeasured amount of broth (cook estimated it to be about one cup). Interview on 07/26/23 at 11:40 A.M., with Dietary Director #101 and Dietary Manager #102 confirmed added bread and broth was not needed to pureed food and could alter the nutritive content of the food. Interview on 07/26/23 at 3:40 P.M., with Dietician #100 revealed staff should not be added a thickening and thinning agent to food to get a proper consistency. Dietician #100 confirmed food should be blended in the original form and then a thickening or thinning agent should be added from there to adjust the consistency as needed. Dietician #100 revealed adding these extra ingredients can take away from the nutritive values of the food items. Dietician #100 also confirmed food should be made according to the recipe and instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 14 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and policy review, the facility failed to ensure safe and sanitary storage of food and to ensure trash cans were covered when in the kitchen. This had the potential to affect all residents, excluding Resident #24 who does not eat food from the kitchen. Facility census was 105. Findings include: Observation on 07/24/23 from 9:37 A.M. to 10:18 A.M. revealed the following findings in the kitchen area. In the refrigerated areas there were the following items uncovered or not dated: over 10 pudding cups undated; two premade salads uncovered; two premade salads undated; over 10 cups of potato salad; six fruit parfait uncovered; over 20 cups of Jello uncovered; over 15 cups of mixed fruit uncovered; a block of cheese slices was uncovered and undated; a opened package of lunch meat was undated; broccoli salad undated; pack of hotdogs undated; green beans with bacon undated; two containers of unidentified red liquid substance (looked similar to vegetable soup) was unlabeled and undated; macaroni and cheese was undated; unknown soup was undated; sausage links were undated; five sheet trays with fruit Jello mix were undated; over 10 pudding cups were undated; cottage cheese uncovered; mixed fruit uncovered; and a bag of diced potatoes had leaked through the cardboard box they were in onto food on the shelf below (this included a box of uncut potatoes and food covered in plastic wrap. In the freezer areas there were uncovered items of: two Styrofoam cups of ice cream uncovered; tater tots open to air; hush puppies open to air and hash brown patties open to air. In dry storage areas there were undated items of: open bag of butter noodles undated; open bag of elbow noodles undated; and a bag of almonds undated. Five uncovered trash cans without lids were observed and two cans were being utilized by staff. Interview on 07/24/23 from 9:37 A.M. to 10:18 A.M., with Dietary Director #101 confirmed findings in the refrigerators, freezers, and dry storage areas and confirmed trash can did not have lids. She revealed staff were using two of the trash cans and asked staff where the other lids were located. Review of the policy titled, Dry Storage, dated 2013, revealed leaking and spoiled foods should be disposed of promptly to prevent contamination of other foods. Refrigerated and frozen foods should be dated upon delivery. Review of the policy titled, Food Safety and Sanitation, dated 2013, revealed food shall be stored and protected from contamination. Food and leftovers should remain covered, labeled, and dated when stored. Review of the policy titled, Waste Disposal, dated 2013, revealed waste shall be kept in leak proof containers that are kept covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 15 of 16 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to maintain resident furniture/equipment in safe working order. This affected one (#72) of one resident reviewed for environment. Facility census was 105. Findings include: Review of the medical record for the Resident #72 revealed an admission date of 10/26/22,with diagnoses including femur fracture, chronic obstructive pulmonary disease, hemiparesis and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. Observation on 07/24/23 at 10:41 A.M., revealed Resident #72's bed side table had two gold ball size chunks broken off with rough edges. Interview on 07/24/23 at 10:42 A.M. with State Tested Nursing Aide (STNA) #201 confirmed residents over the bed table was broken with jagged edges on one side. STNA #201 revealed it had been that way. Interview and observation on 07/26/23 at 3:30 P.M., with Maintenance Director #47 confirmed residents table had broken and rough edges. She revealed no staff had informed the maintenance department of the broken table and confirmed it would be replaced. Maintenance Director #47 revealed facility had no policy regarding equipment and furniture being maintained in good condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 16 of 16