Health inspection·May 26, 2022

F 0550 shaving as desired by resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 2 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0558 Reasonably accommodate the needs and preferences of each resident. 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, observation, staff and resident interview, and policy review the facility failed to ensure the call light was within easy reach of residents. This affected one resident (#24) of 24 residents reviewed. The facility census was 60. Residents Affected - Few Findings include: Review of medical record for Resident #24 revealed admission date of 05/11/21. Diagnoses included stroke, hemiparesis and hemiplegia affecting right dominant side, flaccid hemiplegia left non dominant side and type two diabetes mellitus with diabetic neuropathy. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 required extensive two-person assistance for bed mobility, extensive one person assistance for eating, toilet use, personal hygiene and total dependence for transfers. A care plan for self-care deficit related to right and flaccid hemiplegia requiring assistance. Interventions included the need to evaluate for adaptive equipment. Observation on 05/23/22 at 11:18 A.M., revealed Resident #24's call light was attached to the mattress at his left shoulder area. Resident #24 was unable to reach the call light. Interview on 05/23/22 at 11:42 A.M., with Licensed Practical Nurse (LPN) #73 verified Resident #24 was unable to reach the call light and stated it should be on his gown, she then attached the call light to the middle chest area of his gown. Observation and interview on 05/26/22 at 10:20 A.M. with Resident #24 and Social Worker #19 revealed the call light was attached to the side of the mattress on Resident #24's left side. The Social Worker #19 and Resident #24 verified he was unable to reach the call light attached to the left side of the mattress. The Social Worker #19 moved the call light and placed it on Resident#24's gown at his chest level. Interview on 05/26/22 at 10:20 A.M., with the Director of Nursing (DON), the Social Worker #19, the Administrator and LPN #75 each agreed the call light could not be reached by Resident #24 if it was attached to the side of the mattress. DON #40 suggested a touch call light would be more appropriate, call light teaching would be done with staff and the touch call light would be updated in Resident #24's care plan. Review of the facility policy titled Call Light, last revised on 06/30/17 revealed when the resident is in bed or confined to a chair, be sure the call light is in within easy reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 3 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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, staff interview, and policy review, the facility failed to ensure a resident's code status was accurately documented in the resident's record. This affected one resident (#49) out of 24 residents reviewed for code status. The facility census was 60. Findings include: Review of the medical record revealed Resident #49 admitted to the facility on [DATE]. Diagnoses included bipolar disorder, unspecified dementia without behavioral disturbance, major depressive disorder, malignant neoplasm of unspecified site of unspecified female breast, atrial fibrillation, chronic obstructive pulmonary disease, schizoaffective disorder, glaucoma, and insomnia. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #49 required supervision with bed mobility, transfers, and toilet use. Resident #49 required limited assistance with dressing and Resident #49 also required extensive assistance with personal hygiene. Resident #49 was independent with eating. Review of Resident #49's code status form dated 04/23/19 revealed Resident #49's code status was a do not resuscitate comfort care (DNRCC). The DNRCC form was signed by Resident #49 and the physician on 04/23/19. Review of Resident #49's advanced care planning tracking form dated 02/21/22 revealed Resident #49 was to remain a DNRCC. Review of Resident #49's medication administration record and treatment administration record dated 05/01/22 to 05/31/22 revealed Resident #49 was a full code and a DNRCC. Review of Resident #49's electronic record revealed Resident #49 had an active order for a Full Code status dated 05/18/22. Interview with the Director of Nursing (DON) on 05/24/22 at 11:30 A.M. verified Resident #49's code status in the electronic chart was a full code and Resident #49's code status in the hard chart was a DNRCC. The DON verified Resident #49's code status was a DNRCC and her code status in the electronic chart was incorrect. Review of the facility policy titled Code Status and Audit Process dated 08/12/20 revealed the facility will ensure the resident's code status is accurate and current throughout the resident's stay and the clinical record represents that accurate code status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 4 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record of Resident #57 revealed an admission date of 01/02/19. The resident transferred to another facility on 04/01/22 and returned to the facility, following a hospital stay, on 04/12/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, anxiety, major depressive disorder, essential hypertension, epilepsy, osteoarthritis, moderate protein-calorie malnutrition, polyneuropathy, schizoaffective disorder, dementia with behavioral disturbance, type two diabetes mellitus, and chronic atrial fibrillation. Residents Affected - Few Review of the comprehensive MDS assessment dated [DATE] revealed the resident's cognition was not assessed. The resident required extensive assistance of two staff for bed mobility and toilet use, and was totally dependent on two staff for transfers. The resident was independent after setup for eating. The resident was assessed as having no dental problems, including no broken natural teeth. Review of the Dental Summary Report dated 07/21/21 revealed the resident was assessed has having rampant decay and periodontal disease. Observation on 05/23/22 at 11:06 A.M., revealed the Resident #57 had several broken teeth on the upper front of the resident's mouth. Observation on 05/24/22 at 2:07 P.M., with the Assistant Director of Nursing (ADON) RN #59 verified Resident #57 had several broken teeth in the upper front of the mouth and verified the MDS should have been coded to reflect the resident's broken natural teeth. Interview with the DON on 05/26/22 at 8:11 A.M., revealed the facility follows the Resident Assessment Instrument (RAI) manual and does not have a specific policy on MDS coding. Based on medical record review, observation, and staff and resident interview, the facility failed to ensure resident dental statuses were accurately assessed on the minimum data set (MDS). This affected two residents (#16 and #57) out of 15 residents reviewed for care plans. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #16 admitted to the facility on [DATE]. Diagnoses included gastro esophageal reflux disease without esophagitis, hyperlipidemia, muscle spasm of back, edema, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, bipolar disorder, schizoaffective disorder, primary osteoarthritis left shoulder, and major depressive disorder. Review of Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with transfers, bed mobility, dressing, toilet use, personal hygiene and eating. Resident #16 had no broken or loosely fitting full or partial denture. The MDS assessment revealed Resident #16 was noted as not having no natural teeth, tooth fragments or being edentulous. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and was independent with transfers, bed mobility, dressing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 5 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few toilet use, personal hygiene and eating. Review of Resident #16's had no broken or loosely fitting full or partial denture. Review of Resident #16's dental care plan dated 03/17/16 revealed Resident #16 had only a few natural teeth. Resident #16 did not wear dentures or partials. Resident #16 was at risk for complications from not having a full set of teeth. Interventions included assess oral cavity, consult with the dentist as needed, encourage adequate oral care, and offer assistance as needed and evaluate the need for a dental exam. Review of Resident #16's dental visit dated 11/27/19 revealed Resident #16 was edentulous. Review of Resident #16's dental visit dated 12/21/20 revealed Resident #16 presented for a complete upper and lower denture delivery. Resident #16 was satisfied with the dentures. Review of Resident #16's dental visit dated 01/14/21 revealed resident was edentulous, and his dentures fitted well and the resident was satisfied. Review of Resident #16's dental visit dated 10/14/21 revealed Resident #16 presented for an adjustment of upper denture. Resident #16 also presented with severe gag reflex and advised resident may not be able to tolerate upper dentures. Observation of Resident #16 on 05/23/22 at 10:00 A.M. revealed Resident #16 did not have any natural teeth and was not wearing dentures. Interview with Resident #16 on 05/23/22 at 10:00 A.M., revealed Resident #16 did not have any natural teeth and he was not wearing dentures. Resident #16 stated he had dentures, but they made him gag. Interview with Social Services (SS) #19 on 05/24/22 at 1:54 P.M., revealed Resident #16 was edentulous and had a full set of upper and lower dentures. Interview with Registered Nurse (RN) #59 on 05/24/22 at 2:02 P.M. verified Resident #16 was edentulous and had a full set of upper and lower dentures. RN #59 verified Resident #16's 07/18/21 MDS stated Resident #16 was not edentulous and Resident #16's 07/18/21 MDS was inaccurate in regards to the resident's dental status. Interview with the Director of Nursing (DON) on 05/26/22 at 8:11 A.M. revealed the facility follows the Resident Assessment Instrument (RAI) manual and does not have a specific policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 6 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident with a change in their mental health condition. This affected one resident (#49) out of two residents reviewed for significant change PASARR. The facility census was 60. Findings include: Review of the medical record revealed Resident #49 admitted to the facility on [DATE]. Diagnoses included bipolar disorder, unspecified dementia without behavioral disturbance, major depressive disorder, malignant neoplasm of unspecified site of unspecified female breast, atrial fibrillation, chronic obstructive pulmonary disease, schizoaffective disorder, glaucoma, and insomnia. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #49 required supervision with bed mobility, transfers, and toilet use. Resident #49 required limited assistance with dressing and Resident #49 also required extensive assistance with personal hygiene. Resident #49 was independent with eating. Review of Resident #49's diagnosis list dated 05/24/22 revealed Resident #49 had a diagnosis of schizoaffective disorder bipolar type that was added on 01/13/20 during Resident #49's stay at the facility. Review of Resident #49's PASARR dated 06/27/14 revealed Resident #49 had a mood disorder and Resident #49 had serious indications of mental illness. Resident #49 did not have a diagnosis of schizophrenia. Review of Resident #49's PASARR determination dated 07/07/14 revealed Resident #49 was approved for nursing facility services and did not require a need for specialized services. Review of Resident #49's chart revealed Resident #49 did not have a significant change PASARR or notification to the state mental health authority of Resident #49's diagnosis of schizoaffective disorder bipolar type on 01/13/20. Review of Resident #49's physician visit dated 01/13/20 revealed Resident #20 had a diagnosis of schizoaffective disorder bipolar type. Interview with Social Services (SS) #19 on 05/24/22 at 10:21 A.M., verified Resident #49 did not have a significant change PASARR or notification to the state mental health authority of Resident #49's diagnosis of schizoaffective disorder bipolar type on 01/13/20. Interview with the Director of Nursing (DON) on 05/26/22 at 1:35 P.M. verified Resident #49 received a diagnosis of schizoaffective disorder on 01/13/20 and the diagnosis was made based on a discussion between Resident #49's physician and psychiatrist. Review of the facility policy titled Social Services dated 04/16/21 revealed social services will be responsible for completing PASARRs per federal regulations and any state specific rules. Social services will notify the appropriate state agency promptly after a significant change in condition of a resident who has a mental disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 7 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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, medical record review, staff interview, review of the manufacturers installation recommendations, and policy review, the facility failed to ensure a resident had a care plan for assist bars. This affected one resident (#15) out of 15 residents reviewed for care plans. The facility census was 60. Findings include: Review of the medical record revealed Resident #15 admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, major depressive disorder, muscle weakness, other abnormalities of gait and mobility, constipation, insomnia, edema, and paranoid schizophrenia. Review of Resident #15's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and Resident #15 was independent with bed mobility, transfers, dressing, eating, and toilet use. Resident #15 required supervision with personal hygiene. Review of Resident #15's undated care plan revealed Resident #15 did not have a care plan for bed rails or assist bars. Observation on 05/23/22 at 7:32 A.M. revealed the Director of Nursing (DON) to measure the gap between the assist bar and Resident #15's mattress. There was no gap between the left side of Resident #15's bed and the assist bar that was up against the wall. There was a three inch gap between the assist bar and Resident #15's mattress on the right side of the bed. Resident #15 was observed laying in the bed with the assist bars in the upright position at the time of the observation. Observation on 05/23/22 at 11:09 A.M. revealed Resident #15 had assist bars on both sides of her bed that were in the upright position. Resident #15's left side of her bed was against the wall and the right side of her bed had a large gap between the assist bar and the mattress. Resident #15 was observed laying in her bed. Interview on 05/23/22 at 7:32 A.M. with the DON verified Resident #15 had a three inch gap between the assist bar and Resident #15's mattress on the right side of his bed. The DON also verified there was a piece of the bed at the top that was missing that was supposed to keep the mattress in place. During a follow-up interview on 05/23/22 at 8:37 A.M. with the DON verified Resident #15 did not have a care plan or an assessment for her assist bars. During an follow-up interview with the DON on 05/26/22 at 8:11 A.M. verified Resident #15 had no order for assist bars prior to 05/25/22. Review of the undated manufacturer assist bar installation revealed the mattress must fit firmly against the bed frame and the bed rails to prevent patient entrapment. The manufacture instructions also stated only use the assist position while attending to the resident and return the assist bar to the storage or down position when unattended to avoid patient entrapment from the use of the assist bar in the assist or up position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 8 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 Review of facility policy titled Bed System Dimensions and Assessment Guide undated revealed entrapment may occur in flat or articulated bed positions with the rails fully raised or in intermediate positions. The seven areas in the bed system where there is a potential for entrapment are identified to be within the rail, under the rail, between the rail supports or next to a single rail support, between the rail and the mattress, under the rail at the ends of the rail, between split bed rails, between the ends of the rail and the side edge of the head or foot board or between the head and foot board and the mattress. Dimensional limit recommendations between the rail and the mattress are less than four and three fourth inches. Review of the facility policy titled Comprehensive Care Planning, dated 01/27/11 revealed the facility must develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 9 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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** 2. Review of the medical record revealed Resident #16 admitted to the facility on [DATE]. Diagnoses included gastro esophageal reflux disease without esophagitis, hyperlipidemia, muscle spasm of back, edema, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, bipolar disorder, schizoaffective disorder, primary osteoarthritis left shoulder, and major depressive disorder. Review of Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with transfers, bed mobility, dressing, toilet use, personal hygiene and eating. Resident #16 had no broken or loosely fitting full or partial denture. The MDS assessment revealed Resident #16 was noted as not having no natural teeth, tooth fragments or being edentulous. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and was independent with transfers, bed mobility, dressing, toilet use, personal hygiene and eating. Review of Resident #16's had no broken or loosely fitting full or partial denture. Review of Resident #16's dental care plan dated 03/17/16 revealed Resident #16 had only a few natural teeth. Resident #16 did not wear dentures or partials. Resident #16 was at risk for complications from not having a full set of teeth. Interventions included assess oral cavity, consult with the dentist as needed, encourage adequate oral care, and offer assistance as needed and evaluate the need for a dental exam. Review of Resident #16's dental visit dated 11/27/19 revealed Resident #16 was edentulous. Review of Resident #16's dental visit dated 12/21/20 revealed Resident #16 presented for a complete upper and lower denture delivery. Resident #16 was satisfied with the dentures. Review of Resident #16's dental visit dated 01/14/21 revealed resident was edentulous, and his dentures fitted well and the resident was satisfied. Review of Resident #16's dental visit dated 10/14/21 revealed Resident #16 presented for an adjustment of upper denture. Resident #16 also presented with severe gag reflex and advised resident may not be able to tolerate upper dentures. Observation of Resident #16 on 05/23/22 at 10:00 A.M. revealed Resident #16 did not have any natural teeth and was not wearing dentures. Interview with Resident #16 on 05/23/22 at 10:00 A.M., revealed Resident #16 did not have any natural teeth and he was not wearing dentures. Resident #16 stated he had dentures, but they made him gag. Interview with Social Services (SS) #19 on 05/24/22 at 1:54 P.M., revealed Resident #16 was edentulous and had a full set of upper and lower dentures. Interview with Registered Nurse (RN) #59 on 05/24/22 at 2:02 P.M. verified Resident #16 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 10 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 edentulous and had a full set of upper and lower dentures. RN #59 verified Resident #16's dental care plan was not updated to include Resident #16's full dentures or information regarding Resident #16 being edentulous. Review of the facility policy titled Comprehensive Care Planning, dated 01/27/11 revealed the facility must develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessments. Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure care plans were revised for dental and safety interventions. This affected two residents (#11 and #16) out of 15 residents reviewed for care planning. The facility census was 60. Findings include: 1. Review of the medical record of Resident #11 revealed an admission date of 04/19/16. Diagnoses included alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, schizoaffective disorder, dementia with behavioral disturbance, hyperlipidemia, bipolar disorder, constipation, cognitive communication deficit, essential hypertension, and benign prostatic hyperplasia. Review of the quarterly MDS assessment dated [DATE] revealed the Resident #11 had impaired cognition. The resident was assessed as not having any behaviors during the assessment period. The resident required supervision for bed mobility, transfers, and toilet use, and was independent with eating. Review of the care plan dated 04/04/22 revealed the Resident #11 was at risk for altered behaviors and/or mood related to dementia. Interventions included one-on-one supervision and to place a picture of the resident on the door frame to assist him in identifying his room. Review of the current physician orders revealed Resident #11 had an order dated 05/05/22 for one-on-one supervision. Observation on 05/25/22 at 8:43 A.M., Resident #11 was observed sitting up in his bed, eating breakfast. There were no staff observed in the room with Resident #11. Interview on 05/25/22 at 8:48 A.M., the Licensed Practical Nurse (LPN) #67 stated she was unaware of the need for Resident #11 to receive one-on-one supervision. LPN #67 further verified Resident #11 was not receiving one-on-one supervision. Interview on 05/25/22 at 8:50 A.M., the State Tested Nursing Assistant (STNA) #57 stated she was not aware of the need for Resident #11 to receive one-on-one supervision. Interview on 05/25/22 at 8:51 A.M., the STNA #48 stated she was not aware of the need for Resident #11 to receive one-on-one supervision and further stated she worked on 05/22/22 and Resident #11 did not receive one-on-one supervision at that time. Interview on 05/25/22 at 9:37 A.M., the Director of Nursing (DON) verified Resident #11 had an active order and was care planned for one-on-one supervision and stated the Nurse Practitioner (NP) #300 saw Resident #11 the day after the order for one-on-one supervision was placed, and gave approval (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 11 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 to discontinue the one-on-one supervision order. The DON said the order should have been discontinued and the care plan updated when the order was given. Interview on 05/25/22 at 11:57 A.M., the NP #300 stated she saw Resident #11 the day after the order was entered for one-on-one supervision and gave approval to discontinue the one-on-one supervision. Residents Affected - Few Review of the facility policy titled, Comprehensive Care Planning, dated 01/27/11 revealed the interdisciplinary care plan should be updated as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 12 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review the facility failed to ensure a physician ordered fall preventions were implemented. This affected one resident (#36) of 15 residents reviewed during the annual recertification. The facility census was 60. Findings include: Review of Resident #36's medical record revealed an admission date of 11/16/11. Diagnoses included metabolic encephalopathy, dysphagia, cognitive communication deficit, extrapyramidal and movement disorder, diabetes, chronic kidney disease and hypertension. Review of Resident #36's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was unable to be completed. The MDS revealed the resident required extensive one-person assistance for bed mobility, transfer, dressing, personal hygiene, and toilet use. The resident was independent with set-up for eating. Review of Resident #36's plan of care dated 01/06/22 revealed the resident was at risk for falls related to weakness and administration of psychotropic medications. Interventions included fall mat at bedside, dycem (a mat to prevent sliding) mat to wheelchair, bed in low position, anti-rollbacks on wheelchair, bed against the wall, and non-skid strips to the floor beside the bed. Review of Resident #36's physician orders dated 10/15/21 revealed the resident was to have floor mats beside the resident's bed. Review of the physician order dated 10/25/21 revealed the resident was to have her bed against the wall due to the resident's preference and enhancement of the room, and non-skid strips on the resident's floor beside the bed. Review of the physician orders dated 11/09/21 revealed the anti-tip to the wheelchair and the dycem mat in the wheelchair. Observation on 05/26/22 at 9:03 A.M. of Resident #36 sitting in her wheelchair in her room revealed no dycem mat was observed in the resident's wheelchair. There were no non-skid strips on the floor along the resident's bed. The bed was not positioned against the wall per the physician's orders. Interview and observation on 05/26/22 at 10:26 A.M. with the Director of Nursing (DON) and the Physical Therapist (PT) #303 confirmed Resident #36 did not have a dycem mat in her wheelchair, did not have non-skid strips on the floor beside the resident's bed. The DON and PT #303 confirmed the resident's bed was not against the wall per the physician's order and the resident's preference. Review of the facility policy titled Fall Prevention and Management, dated 12/09/19 revealed residents will be assessed for fall risk and preventive measures will be put in place and identified on the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 13 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, review of manufacturers instructions, and policy review, the facility failed to ensure a resident's assist bars were installed per manufacture instructions. This affected one resident (#15) out of 15 residents reviewed for care plans. The facility census was 60. Findings include: Review of the medical record revealed Resident #15 admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, major depressive disorder, muscle weakness, other abnormalities of gait and mobility, constipation, insomnia, edema, and paranoid schizophrenia. Review of Resident #15's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and Resident #15 was independent with bed mobility, transfers, dressing, eating, and toilet use. Resident #15 required supervision with personal hygiene. Review of Resident #15's undated care plan revealed Resident #15 did not have a care plan for bed rails or assist bars. Observation on 05/23/22 at 7:32 A.M. revealed the Director of Nursing (DON) to measure the gap between the assist bar and Resident #15's mattress. There was no gap between the left side of Resident #15's bed and the assist bar that was up against the wall. There was a three inch gap between the assist bar and Resident #15's mattress on the right side of the bed. Resident #15 was observed laying in the bed with the assist bars in the upright position at the time of the observation. Observation on 05/23/22 at 11:09 A.M. revealed Resident #15 had assist bars on both sides of her bed that were in the upright position. Resident #15's left side of her bed was against the wall and the right side of her bed had a large gap between the assist bar and the mattress. Resident #15 was observed laying in her bed. Interview on 05/23/22 at 7:32 A.M. with the DON verified Resident #15 had a three inch gap between the assist bar and Resident #15's mattress on the right side of his bed. The DON also verified there was a piece of the bed at the top that was missing that was supposed to keep the mattress in place. During a follow-up interview on 05/23/22 at 8:37 A.M. with the DON verified Resident #15 did not have a care plan or an assessment for her assist bars. During an follow-up interview with the DON on 05/26/22 at 8:11 A.M. verified Resident #15 had no order for assist bars prior to 05/25/22. Review of the undated manufacturer assist bar installation revealed the mattress must fit firmly against the bed frame and the bed rails to prevent patient entrapment. The manufacture instructions also stated only use the assist position while attending to the resident and return the assist bar to the storage or down position when unattended to avoid patient entrapment from the use of the assist bar in the assist or up position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 14 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of facility policy titled Bed System Dimensions and Assessment Guide undated revealed entrapment may occur in flat or articulated bed positions with the rails fully raised or in intermediate positions. The seven areas in the bed system where there is a potential for entrapment are identified to be within the rail, under the rail, between the rail supports or next to a single rail support, between the rail and the mattress, under the rail at the ends of the rail, between split bed rails, between the ends of the rail and the side edge of the head or foot board or between the head and foot board and the mattress. Dimensional limit recommendations between the rail and the mattress are less than four and three fourth inches. Event ID: Facility ID: 366099 If continuation sheet Page 15 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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, chemical supply technician interview, and policy review, the facility failed to maintain equipment and store food and supplies in a manner to prevent the potential spread of food borne illness. This had the potential to affect all 60 residents residing in the facility. Findings include: 1. Observation on 05/23/22 at 8:25 A.M. revealed a large standing fan in the kitchen, coated in a dark grey furry substance, facing the tray line, and in the on position. Staff were observed preparing breakfast trays from the tray line. Interview on 05/23/22 at 8:29 A.M., [NAME] #22 verified the fan was dirty, on, and facing the food on the tray line. 2. Observation on 05/25/22 at 9:07 A.M. revealed a large standing fan, in the on position, facing the three-compartment sink and clean, drying dishes. The fan was observed to be coated in a grey, furry substance. Interview at the time of the observation with Food Service Supervisor (FSS) #21 verified the fan was dirty, on, and facing clean dishes. 3. Observation on 05/23/22 at 8:31 A.M. revealed four milk crates containing small cartons of milk and gallons of milk, stored directly on the floor of the walk-in refrigerator. Interview at the time of the observation with [NAME] #22 verified the milk was stored on the floor. [NAME] #22 stated they had been trying to get the milk delivery person to not place the milk on the floor. [NAME] #22 stated the milk was delivered on Thursdays and was last delivered on 05/19/22. Review of the facility policy titled, Storage of Refrigerated Foods, dated 02/19/19, revealed all refrigerated items must be stored on shelving or dollies at least six inches above the floor. 4. Observation on 05/23/22 at approximately 11:00 A.M. revealed FSS #21 ran the dishwasher several times. FSS #21 stated the temperature of the machine needed to reach 120 degrees Fahrenheit. Continuous observation of dishwasher cycles revealed the highest temperature the dishwasher reached was 115 degrees. During an interview at the same time, FSS #21 verified the dishwasher read 110-115 degrees after approximately five full cycles. Follow-up interview on 05/23/22 at 1:14 P.M., FSS #21 stated the dishwasher temperatures had been fluctuating for the past few months and maintenance had last looked at the dishwasher last month. Interview on 05/23/22 at 1:32 P.M., the Administrator denied knowledge of any food borne illness in the facility during the last several months. 5. Observation on 05/23/22 at approximately 11:35 A.M. revealed FSS #21 inserted a testing strip into the sanitizing tank of the three-compartment sink. The strip indicated the sanitizer level was read between 50 and 100 parts per million (PPM). The FSS #21 stated the level was supposed to be 150-200 ppm. FSS #21 stated she identified the sanitizer levels as a problem recently, so staff were emptying the sink and refilling it more often. During a follow-up interview with FSS #21 on 05/23/22 at 4:15 P.M., FSS #21 stated she called the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 16 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 chemical supplier regarding the malfunctioning equipment for the three-compartment sink a few weeks ago. Level of Harm - Minimal harm or potential for actual harm 6. Observation on 05/23/22 at approximately 1:15 P.M. revealed [NAME] #31 preparing to wash dishes from lunch. [NAME] #31 stated she normally checked the sanitizer level of the dish machine after she was done doing the dishes. Upon surveyor request, [NAME] #31 took a sanitizing testing strip out of the container of strips to test the sanitizer level. After dipping the strip, the strip remained white, reading 0 ppm. [NAME] #31 took approximately 4 more testing strips from the container to test the sanitizing level, and all read 0 ppm. [NAME] #31 verified the strips read 0 ppm on all tests. Continued observation of the dish machine cycles revealed the highest temperature the dishwasher reached during approximately four cycles was 110 degrees Fahrenheit. Residents Affected - Many Observation and interview on 05/23/22 at 4:12 P.M. revealed the Chemical Supply Technician #301 working on the dish machine. Chemical Supply Technician stated there was a crack in the line to the sanitizer bucket and he had repaired it at this time. Chemical Supply Technician #301 stated he was last in the facility for the dishwasher four weeks prior and further stated he was originally scheduled to come for repairs the following day (05/24/22), however was instructed to come today instead. Observation on 05/25/22 at approximately 9:00 A.M. revealed the dishwasher cycle reached 121 degrees Fahrenheit and the sanitation tank of the 3-compartment sink quaternary solution read between 150 and 200 ppm. Review of the facility policy titled, Cleaning and Sanitizing, undated, revealed the dishwasher operator will check temperatures using the machine gauge frequently during the dish machine cycle and test the sanitizer strength before the machine is used following each meal. The wash cycle should reach 120 degrees Fahrenheit and the final rinse should reach 50 ppm chlorine. If inadequate temperatures or sanitizer strengths are noted, use of the dishwasher should immediately be discontinued and reported to the supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 17 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #42's medical record revealed an admission date of 09/18/20. Diagnoses included chronic obstructive pulmonary disease, acute kidney failure, atrial fibrillation, extrapyramidal and movement disorder, and paranoid schizophrenia. Residents Affected - Some Review of Resident #42's Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment. The MDS revealed the resident required supervision with one-person physical assist for dressing, toilet use, and personal hygiene. The resident required supervision with set-up for eating, bed mobility, and transfer. Review of Resident #42's plan of care dated 05/04/22 revealed the resident required medication management related to resident's cognitive deficit and mental health concerns. Observation on 05/24/22 at 7:14 A.M. of medication administration for Resident #42 provided by Licensed Practical Nurse (LPN) #303 revealed the nurse dispensed the pills from the pharmacy card directly into the nurse's hand, then transferred to the medicine cup. The nurse was observed dispensing the following medications into her hand: Norvasc (a antihypertensive medication) five milligram (mg), benztropine (an anticholinergic medication) 0.5 mg, Depakote (an seizure medication) 250 mg, metoprolol (an antihypertensive medication) 25 mg, Losartan (a beta blocker) 50 mg, and Invega (an antipsychotic medication) Extended Release three mg. Interview on 05/24/22 at 7:31 A.M., with LPN #303 verified she dispensed the medications directly into her bare hand. Interview on 05/24/22 at 2:44 P.M. with the Director of Nursing (DON) verified dispensing medications directly into the nurse's hand or touching medications with an ungloved hand was not acceptable. Review of the facility policy titled General Dose Preparation and Medication Administration, dated 12/01/07 revealed facility staff should not touch the medication and if a medication was dropped, the medication should be discarded. 3. Review of Resident #50's medical record revealed an admission dated of 10/28/21. Diagnoses included hereditary and idiopathic neuropathy, depression, chronic obstructive pulmonary disease, and hypertension. Review of Resident #50's MDS dated [DATE] revealed the resident had intact cognition. The MDS revealed the resident required supervision with set-up for transfer, dressing, personal hygiene, toilet use, and eating. The resident was independent with bed mobility. Review of Resident #50's plan of care dated 04/26/22 revealed the resident had a self-care deficit and required assistance with medication administration. Observation on 05/24/22 at 8:12 A.M. of medication administration for Resident #50 provided by LPN #73 revealed the nurse dropped the resident's Topamax (a seizure medication) 50 mg tablet on the cart, picked the medication up with her ungloved fingers and placed the medication in the medication cup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 18 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/24/22 at 8:20 A.M. with LPN #73 verified she dropped the medication on the cart and she picked the medication up with her ungloved hand. The LPN #73 verified she should have discarded the medication and obtained a new Topamax 50 mg tablet. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated 12/01/07 revealed facility staff should not touch the medication and if a medication was dropped, the medication should be discarded. Based on medical record review, observation, interview and policy review, the facility failed to ensure residents were placed in appropriate transmission based precautions upon admission. This had the potential to affect 32 residents (#01, #03, #04, #05, #07, #10, #13, #15, #16, #18, #21, #24, #25, #26, #29, #31, #32, #37, #38, #39, #44, #45, #46, #49, #50, #51, #54, #58, #60, #463, #464, and #465) residing on the East Unit. In addition the facility failed to ensure medications were not handled with bare hands prior to administration. This affected two residents (#42 and #50) of three residents observed for medication administration. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included unspecified anemia, major depressive disorder, unspecified acute kidney failure, and unspecified cerebral infarction. Review of most recent Minimum Daily Set (MDS) assessment dated [DATE] revealed Resident #58 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #58 required one-staff assistance and supervision with bed mobility and locomotion, limited assistance with transfers and personal hygiene, and extensive assistance with dressing and toilet use, and was independent with eating. Review of the immunizations revealed Resident #58 received one dose of COVID-19 vaccination on 09/29/21 and refused to consent to further COVID-19 vaccinations. Review of Resident #58's physician orders dated 05/23/22 revealed combined droplet/contact precautions and isolation per transmission based precautions. All care and services were provided in the resident's room. Isolation was discontinued when the resident met the criteria for discontinuation of isolation as per the Centers for Disease Control (CDC) guidelines using either symptom-based or testing-based strategies. Review of the progress notes revealed Resident #58 was sent to a local medical center on 05/19/2022 at 12:03 P.M. for a scheduled surgery to have fluid removed from the prepatellar bursitis with an overnight stay for observation. Resident #58 returned to the facility on [DATE] at 3:00 P.M. Resident #58 was placed in isolation on 05/23/2022 at 12:16 P.M. Observation on 05/23/2022 from 9:29 A.M. to 9:52 A.M. revealed there were no isolation carts and no residents identified with Transmission based precautions located on the East Hall. During an interview on 05/24/22 at 9:41 A.M., the Director of Nursing (DON) verified Resident#58 was not fully vaccinated, had been out of the facility for 27 hours, and should have been placed in combined contact and droplet precautions for COVID isolation upon return from the hospital. Resident #58 tested negative on 05/23/2022 and had no signs and symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 19 of 20 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 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a follow-up interview on 05/25/22 at 2:34 P.M., the DON stated residents on the yellow unit were in combined contact/droplet precautions for COVID-19 isolation. Review of policy titled admission COVID Protocol dated 04/04/2022 revealed new admissions who have not been COVID-positive in the last 90 days and are not up to date on vaccinations (had received all recommended doses in the primary series and one booster, when eligible) were placed in the yellow unit. New admissions were COVID tested within 24 hours of admission, and if negative, again between five to seven days. If the second test was negative, the resident was moved to the green unit. The policy did not define what type of transmission-based precautions were used on each unit. Review of policy titled Transmission-Based Precautions Policy revised 05/20/2021 revealed residents with confirmed or suspected COVID-19 were placed in combined airborne and and droplet precautions which included gloves, gown, eye protection and N 95 respirator. Residents placed on precautions due to identified potential exposure remained in isolation for 10 days after exposure as long as they had not developed symptoms or until day seven if they tested negative between days five to seven if they had not developed symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366099 If continuation sheet Page 20 of 20