Health inspection·March 20, 2025

F 0686 01/20/25: stage three, 1 cm by 1 cm by 2.3 cm. with yellow drainage; Level of Harm - Minimal harm or potential for actual harm 01/29/25: stage three, 1.2 cm. by 1 cm. by 3.0 cm. with yellow drainage; 02/05/25: stage three 1.5 cm. by 1 cm by 3.0 cm. with yellow drainage; Residents Affected - Few 02/13/25: stage three 1.2 cm. by 0.8 cm by 2.7 cm. with yellow drainage; 02/20/25: stage three 1.5 cm. by 1.3 cm by 2.2 cm. with yellow drainage; 02/27/25: stage three 1.5 cm. by 1 cm by 2.5 cm. with yellow drainage; 03/05/25: stage three 1.3 cm. by 1 cm by 2.5 cm. with yellow drainage; and 03/20/25: stage three 1.2 cm. by 1.3 cm by 2.0 cm with yellow drainage and a mild odor. Review of the physician orders dated 01/22/25, for Resident #18, revealed to cleanse the coccyx with Vashe wound cleanser, pat dry, pack the wound with damp Betadine ¼ inch packing and stimulant Collagen powder and cover with Gentac silicone adhesive bandage and change 1-2 times day and as needed for soilage. These were missed on 02/05/25, 02/16/25, and 02/19/25. Review of physician orders dated 02/21/25, for Resident #18, revealed to cleanse the coccyx with Vashe wound cleanser, pat dry, pack the wound with damp Betadine ¼ inch packing and apply Calcium Alginate to excoriated areas and cover with Gentac silicone adhesive bandage and change 1-2 times day and as needed for soilage. These were missed on 02/21/25, 02/22/25, 02/26/25 and 02/27/25. Review of physician orders dated 02/28/25, for Resident #18, revealed to cleanse the coccyx with Vashe wound cleanser, pat dry, pack the wound with damp Betadine ¼ inch packing and stimulant Collagen powder to depth and place Calcium Alginate to the excoriated areas and cover with Gentac silicone adhesive bandage and change 1-2 times day and as needed for soilage. These were missed on 02/28/25, 03/02/25, and 03/05/25. Review of the physician orders dated 03/06/25, for Resident #18, revealed to cleanse the coccyx with Vashe wound cleanser, pat dry, pack the wound with Perochol AG, apply Calcium Alginate to the excoriation and cover with border foam dressing and change 1-2 times day and as needed for soilage. These were missed on 03/06/25 and 03/10/25. Review of dressing changes from 02/01/25 through 03/20/25 revealed they were blank for documentation of the completion of the dressing change on 02/16, 02/19, 02/21, 02/22, 02/23, 02/26, 02/28, 03/02, 03/06, 03/10, and 03/17/25. Review of the progress notes from 02/01/25 through 03/20/25 revealed there was no evidence of why the above mentioned dressing changes were not completed, if there were new strategies for wound healing, and no IDT notes concerning this wound. Further review revealed there wasn't any notes the resident refused the dressing changes either. Observation of a dressing change for Resident #18 revealed Licensed Practical Nurse (LPN) #144 on 03/19/25 at 9:25 A.M., revealed he was not resistant to the dressing change and the wound had a dressing on it dated 03/18/25. The old dressing had exudate on it and the wound appeared to be a hole the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 2 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett 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 0686 size of a dime. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 03/20/25 at 1:30 P.M., revealed she confirmed there were dressing changes that weren't done. She reported there had been conversations with the wound clinic about the resident's wound, and agreed the wound had stalled and should have been healed by now. She blamed in on the resident and said he would pick off his dressing and refuse dressing changes but didn't have notes of when this happened. Residents Affected - Few An interview with the Nurse Practitioner (NP) #200 from the wound clinic on 03/20/25 at 12:51 P.M. revealed Resident #18's wound has been treated by the wound clinic since 07/18/24. She said the wound should be healed by now, but it is stalling, and she feels like it is contributed to the treatment that isn't either getting done consistently or not done at all. She reported that the staff are not putting enough packing into the wound, at times when the resident comes to the clinic the packing isn't in the wound, and there isn't a bandage on the wound. The family reported to her sometimes when they take him out for dinner he has a Band-Aid on his wound. She reported that if the treatments were being done at the facility as they are ordered the wound would be showing signs of improvement. She reported she has spoke to the DON several times on how can we get this wound healed and the resident still has the wound. Review of the policy entitled Wound Care dated 2001 revealed the following: Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 3 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett 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 0686 2. Report other information in accordance with facility policy and professional standards of practice. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00163298 and Complaint Number OH00163144. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 4 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, medical administration record review, staff schedule review, staff interview, agency staff interview, resident interview, and policy review, the facility failed to ensure there was enough staff available to pass medications in a timely manner. The affected 51 (#1, #2, #3, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #20, #22, #24, #25, #26, #27, #28, #35, #36, #37, #38, #39, #41, #42, #43, #45, #46, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #62, #63, #65, #67, #68, #69, #70, and #72) of 51 residents reviewed for staffing needs. The census was 71. Findings included: Review of the electronic Medication Administration Record (MAR) on 03/19/25 between 11:11 A.M. and 2:00 P.M., revealed 51 (#1, #2, #3, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #20, #22, #24, #25, #26, #27, #28, #35, #36, #37, #38, #39, #41, #42, #43, #45, #46, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #62, #63, #65, #67, #68, #69, #70, and #72) had not received the physician ordered mediations as ordered for the morning of 03/19/25. Review of the nurse schedule dated 03/19/25 revealed there were three nurses scheduled, two being from agency and one from the facility. The schedule reflected the two agency nurses called off and the other nurse came in at 7:45 A.M. Interview with Resident #70 on 03/19/25 at 10:10 A.M., revealed she received her medications late at times and didn't know why. Interview and observation of the computer screen with Licensed Practical Nurse (LPN) #144 on 03/19/25 at 11:11 A.M., revealed she had medications pulled up for the residents and they were red indicating they were late to administer. The LPN reported she was late with her medications because there weren't any nurses in the building at 7:00 A.M. and she got called into work. Interview and observation of the computer screen with agency LPN #202 on 03/19/25 at 11:51 A.M., revealed he arrived at the facility at 9:20 A.M. because he signed up for a shift at the facility. He stated he didn't know the facility had opened until this morning. He reported he was late with his medications and his computer screen was red which indicated the medications for the residents were late. Interview with Resident #65 on 03/19/25 at 1:11 P.M., revealed he was supposed to get his medication at 8:00 A.M. Resident #65 stated it keeps getting later and later that he receives them. Resident #65 reported his medications were given to him today at 11:30 A.M. Resident #65 stated if it is the regular nurses who work, he gets them on time, but if it is agency nurses they were late. Interview with the Director of Nursing (DON) on 03/19/25 at 2:10 P.M., confirmed that the residents didn't get their medications until late, and the physician was notified and approved they were late. She reported there were two agency nurses who called off for 03/19/25 and when that happens no one in the facility knows they weren't coming, because the agency sends an email at 5:00 A.M. and no one looks at their email that early. She confirmed there weren't enough nurses this A.M. because their regular nurse was scheduled to come in at 7:00 A.M. and didn't arrive until 7:45 A.M. and confirmed this was why the medications were late. She stated she was off on 03/17/25 and the same thing happened because they had some call-offs from agency and didn't catch it till later, which made the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 5 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett 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 0725 medications late on some halls. Level of Harm - Minimal harm or potential for actual harm Review of the undated policy titled, Staffing revealed licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. Residents Affected - Some This deficiency represents non-compliance investigated under Master Complaint Number OH00163298 and Complaint Number OH00163144. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 6 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, computer medication administration record review, staff schedule review, staff interview, agency staff interview, and resident interview and policy review, the facility failed to ensure the continuity of staff to administer medications within the physician ordered time frames. The affected 51 (#1, #2, #3, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #20, #22, #24, #25, #26, #27, #28, #35, #36, #37, #38, #39, #41, #42, #43, #45, #46, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #62, #63, #65, #67, #68, #69, #70, #72) of 51 residents reviewed for late mediations. The census was 71. Findings included: 1. Medical record review for Resident #1 revealed an admission date of 02/07/25. Medical diagnoses included coronary artery disease, (CAD) heat failure, diabetes mellitus (DM), and renal insufficiency. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #1 was ordered to receive Tylenol 325 milligram (mg) to be given two tablets two times a day, Scopolamine Patch one mg to apply every three days, Duloxetine 60 mg once a day, Metoprolol 25 mg give 12.5 mg on time a day, Ezetimlbe 10 mg once a day, and Mirabegron 50 mg once a day. All of these medications were ordered for 8:00 A.M. and given at 11:01 A.M. 2. Medical record review for Resident #2 revealed an admission date of 07/10/24. Medical diagnoses included cerebrovascular attack (CVA), hypertension (HTN) and acute respiratory failure. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #2 was to order to receive Ticagelor 80 mg give twice a day, Lactulose 30 milliliters (ml.) daily, Prozac 40 mg once a day, and Aspirin 81 mg once a day. All of these medications were ordered for 8:00 A.M. and not given till 11:00 A.M. 3. Medical record review for Resident #3 revealed an admission date of 01/15/24. Medical diagnoses included HTN, DM and Schizophrenia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #3 was to receive Zoloft 25 mg one time a day. This medication was ordered for 8:00 A.M. and not given till 12:54 P.M. 4. Medical record review for Resident #5 revealed an admission date of 08/13/24. Medical diagnoses included HTN, non-traumatic brain injury (NTBI), and dementia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #5 was to receive Lisinopril 5 mg once a day in the morning, Famotidine 20 mg in the morning, Citalopram 5 mg in the morning once a day. These medications were ordered for 7:00 A.M. and given at 1:04 P.M. 5. Medical record review for Resident #6 revealed an admission date of 02/07/24. Medical diagnoses included heart failure, HTN, pneumonia (PNA), and DM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 7 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #6 was to receive Carvedilol 6.25 mg in the morning, Aspirin 81 gm once a day, Sprionolactone 25 mg one time a day, Metformin 1,000 mg every morning, Escitalopram Oxalate 10 mg once a day, Lisinopril 5 mg once a day. These medications were ordered for 8:00 A.M. and given at 10:04 A.M. 6. Medical record review for Resident # 7 revealed an admission date of 02/07/24. Medical diagnoses included CVA dementia, seizure disorder, and schizophrenia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #7 was to receive Lorazepam 0.5 mg twice a day, Keppra 500 mg two times a day. The first dose of these medications were ordered to be given at 8:00 A.M. and not given till 9:56 A.M. 7. Medical record review for Resident #9 revealed an admission date of 10/06/23. Medical diagnoses included heart failure, DM and arthritis. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #9 was to receive Aspirin 81 mg once a day, Metoprolol 50 twice a day, Effexor extended release 75 mg (give three) once a day, Pepcid 20 mg two times a day, Lasix 40 mg once a day, Oxycodone 5 mg (give 2.5 mg) two times a day, and Potassium 10 milliequivalent (MEQ) once a day. These medications were ordered for 8:00 A.M. and given at 10:35 A.M. 8. Medical record review for Resident #10 revealed an admission date of 12/13/24. Medical diagnoses included there wasn't any. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #10 was to receive Jardiance 10 mg once a day, Escitalopram Oxalate 20 mg once a day, Elliquis 5 mg two times a day, Lasix 20 mg once a day, Omeprazole 20 mg once a day, Lacosamide 100 mg once a day, Depakote delayed release 125 mg once a day, Lactobacillus 100 mg once a day for 21 days, Metoprolol 25 mg two times a day, Potassium extended release 20 MEQ once a day, Ropinirole Hydrochloride extended release 2 mg once a day, Trelegy Ellipta Inhalation 100-62.5-25 micrograms (MCG) once a day, Buspirone 15 mg in the morning, and Hydroxyzine 10 mg in the morning. These medications were ordered to be given at 8:00 A.M. and were given at 10:40 A.M. Also Gabapentin 300 mg was scheduled at 9:00 A.M. and was given at 10:40 A.M. 9. Medical record review for Resident #11 revealed an admission date of 05/07/24. Medical diagnoses included there wasn't any. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #11 was to receive Abilify 5 mg (give 2.5 mg) daily, Sertraline 25 mg in the morning, and Paroxetine HCI in the morning. These medications were ordered for 7:00 A.M. and not given till 12:50 P.M. Further review revealed Doxycycline 100 mg two times a day, Torsemide twice a day, Coreg 6.25 mg twice a day, Buspirone HCI once a day, Allopurinol 100 mg once a day, and Metolazone 2.5 mg in the morning. These medications first dose was ordered for 8:00 A.M. and given at 12:48 P.M. 10. Medical record review for Resident #12 revealed an admission date of 12/20/24. Medical diagnoses included HTN and DM. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #12 was to receive Lisinopril 2.5 mg once a day, Rivaroxaban 10 mg once a day, Metformin 500 mg two times a day, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 8 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Jardiance 10 mg once a day, and Venlafaxine HCI 75 mg once a day. The medication first dose was ordered for 8:00 A.M. and given at 10:23 A.M. 11. Medical record review for Resident #14 revealed an admission date of 11/15/20. Medical diagnoses included coronary artery disease (CAD), HTN, dementia, and schizophrenia. Residents Affected - Some Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #14 was to receive revealed Geodon HCI 20 mg in the morning, Wellbutrin XL extended release 150 mg once a day, Plavix 75 mg once a day, Auvelity extended release 45-105 mg once a day. These medications were ordered for 8:00 A.M. and given at 11:59 A.M. 12. Medical record review for Resident #15 revealed an admission date of 02/18/25. Medical diagnoses included renal failure and benign prostatic hyperplasia (BPH). Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #15 was to receive Tamsulosin HCI 0.4 mg two times a day, Aspirin 81 mg once a day, Memantine HCI 10 mg two times a day, Allopurinol 100 mg once a day and Atenolol 12.5 mg once a day. The first dose of these medications was ordered for 7:00 A.M. and was given at 11:21 A.M. 13. Medical record review for Resident #16 revealed an admission date of 09/12/24 Medical diagnoses included CVA, heart failure, peripheral vascular disease (PVD), and neurogenic bladder. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #16 was to receive Tizanidine HCI 4 mg (two) twice a day, Levetiracetam 500 mg twice a day, Colace 100 mg twice a day, Pepcid 20 mg in the morning, Gabapentin 300 mg three times a day, Spironolactone 25 mg once a day, Plavix 75 mg once a day, Oxybutynin Chloride ER 5 mg once a day, Xarelto 10 mg once a day, Tylenol with codeine 300-30 mg three times a day, Losartan Potassium 100 mg once a day, Carvedilol 6.25 mg twice a day, Buspirone HCI 5 mg twice a day, Wellbutrin XL 300 mg in the morning, Methocarbamol 500 mg three times a day. The first dose was ordered for 8:00 A.M. and given at 1:07 P.M. 14. Medical record review for Resident #17 revealed an admission date of 12/29/22. Medical diagnoses included dementia, CVA and hemiplegia and hemiparesis. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #17 was to receive Zoloft 25 mg once a day, Plavix 75 mg once a day, Levothyroxine Sodium 25 mcg once a day. These medications were ordered for 9:00 A.M. and were given at 10:18 A.M. 15. Medical record review for Resident #18 revealed an admission date of 12/29/22. Medical diagnoses included dementia, CVA and hemiplegia and hemiparesis. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #18 was to receive Renaxa 1,000 mg twice a day, Zoloft 50 mg once a day, Isosorbide Mononitrate ER 30 mg once a day, Amlodipine Besylate 5 mg once a day, Plavix 75 once a day, Abilify 5 mg once a day, Depakote 350 mg twice a day, Sulcralfate 1 gram three times a day, Levetiracetam 500 mg twice a day, Famotidine 20 mg two times a day, and Losartan Potassium 50 mg once a day. These medications were ordered for 9:00 A.M. and not given till 11:25 A.M. 16. Medical record review for Resident #20 revealed an admission date of 12/29/22. Medical diagnoses included dementia, CVA and hemiplegia and hemiparesis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 9 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #20 was to receive Lexapro 10 mg once a day, Robaxin 750 mg four times a day, Vistaril 25 mg twice a day, Pepcid 20 mg twice a day, Labetalol HCI 200 mg two times a day, Amlodipine Besylate 10 mg once a day, Isosorbide Monitrate ER on ce a day in the morning, and Clonidine HCI 0.2 mg three times a day. The first dose of the medication was ordered for 8:00 A.M. and given at 10:13 A.M. Residents Affected - Some 17. Medical record review for Resident #22 revealed an admission date of 12/30/22. Medical diagnoses included atrial fibrillation (A-fib) PNA, hip fracture, and respiratory failure. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #22 was to receive Lasix 20 mg once a day, Metoprolol 50 mg twice a day, Doxycycline Hyclate two times a day, Elliquis 2.5 mg twice a day. The first dose of these medications was ordered for 8:00 [NAME] given at 10:25 A.M. Further review of the orders revealed Diltiazem HCI 60 mg three times a day. The first dose of this medication was ordered for 9:00 A.M. and given at 10:25 A.M. 18. Medical record review for Resident #24 revealed an admission date of 12/30/22. Medical diagnoses included A-fib, CAD, heart failure, HTN, PVD, and DM. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #24 was to receive Claritin 10 mg once a day, Lasix 40 mg once a day, Potassium Chloride ER 20 MEQ once a day, Lisinopril 40 mg once a day, Elliquis 5 mg twice a day, Aspirin 81 mg once a day, Lasix 20 mg once a day, Coreg 12.5 mg twice a day, Hydralazine 50 mg three times a day. The first dose of these medications was ordered for 8:00 A.M. and given 11:20 A.M. 19. Medical record review for Resident #25 revealed an admission date of 08/25/23. Medical diagnoses included DM, dementia, and chronic obstructive pulmonary disease (COPD). Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #25 was to receive Buspirone HCI 5 mg once a day, Ativan 0.5 mg two times a day, Amlodipine Besylate 2.5 mg once a day, Plavix 75 mg once a day, Metformin HCI 1,000 mg twice a day, Memantine HCI once a day, Ramipril 5 mg once a day, Aspirin 81 mg once a day, Isosorbide Mononitrate ER 30 mg (two) once a day, Depakote 250 mg (two) two times a day, and Prozac 20 mg once a day. The first dose of these medications were ordered for 8:00 A.M. and given 11:51 A.M. 20. Medical record review for Resident #26 revealed an admission date of 09/13/24. Medical diagnoses included DM, dementia and COPD. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #26 was to receive Lamictal 100 mg twice a day, Vistaril 25 mg (two) three times a day, Ativan 1 mg twice a day, and Lithium Carbonate 150 mg three times a day The first dose of these medications were ordered for 8:00 A.M. and given 10:26 A.M. 21. Medical record review for Resident #27 revealed an admission date of 12/29/22. Medical diagnoses included heart failure, HTN, renal insufficiency, and respiratory failure. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #27 was to receive Hydrochlorothiazide 25 mg once a day and Amlodipine Besylate 10 mg once a day. These medications were ordered for 8:00 A.M. and given at 9:56 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 10 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 22. Medical record review for Resident #28 revealed an admission date of 04/04/23. Medical diagnoses included PNA, Alzheimer's, dementia, and hip fracture. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #28 was to receive Aspirin 81 mg once a day, Gabapentin 100 mg twice a day, Metoprolol 25 mg every 12 hours, and Omeprazole 10 mg (four) in the morning. The first dose of the medications was ordered for 8:00 A.M. and given at 9:59 A.M. 23. Medical record review for Resident #35 revealed an admission date of 03/01/25. Medical diagnoses included there wasn't any. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #35 was to receive Prednisone 2.5 mg once a day in the morning, Tamsulosin HCI 0.4 mg in the morning, Metoprolol ER 25 mg in the morning, Allopurinol 300 mg in the morning, Levofloxacin 500 mg in the morning for seven days, Elliquis 2.5 mg twice a day, Lasix 20 mg once a day, Gabapentin 800 mg four times a day, Icosapent Ethyl 1 gram (two) twice a day, and Memantine HCI 5 mg two times a day. The first dose of the medication was ordered for 8:00 A.m. and given at 12:54 P.M. 24. Medical record review for Resident #36 revealed an admission date of 02/07/25. Medical diagnoses included CAD, HTN, DM and seizure disorder. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #36 was to receive Humalog Injection Solution to inject four units subcutaneously with meals, Plavix 75 mg once a day, Topiramate 200 mg twice a day, and Metoprolol 25 mg two times a day. The first dose of these medications was ordered for 8:00 A.M. and given at 11:02 A.M. 25. Medical record review for Resident #37 revealed an admission date of 02/25/25. Medical diagnoses included there wasn't any listed. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #37 was to receive Fenofibrate 48 mg once a day, Citalopram 20 mg once a day, Lisinopril 5 mg once a day, Levetiracetam 500 mg twice a day, and Diclofenac 75 mg twice a day. The first dose of these medications was ordered for 8:00 A.M. and given at 9:57 A.M. 26. Medical record review for Resident #38 revealed an admission date of 06/07/24. Medical diagnoses included neurogenic bladder, DM and paraplegic. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #38 was to receive Duloxetine HCI 60 mg once a day, Citalopram 100 mg once a day, and Gabapentin 800 mg four times a day. The first dose of these medication was ordered for 8:00 A.M. and given at 10:01 A.M. 27. Medical record review for Resident #39 revealed an admission date of 02/18/25. Medical diagnoses included heart failure, and thyroid disorder. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #39 was to receive Duloxetine 60 mg once a day and ordered for 8:00 A.M. and given at 10:00 A.M. 28. Medical record review for Resident #41 revealed an admission date of 11/07/23. Medical diagnoses included renal failure, Alzheimer's and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 11 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #41 was to receive Depakote 125 mg (three) in the morning, Ativan 0.5 mg every morning, Protonix 20 mg once a day, and Memantine HCI 10 mg every 12 hours. The first dose of the medication was ordered for 8:00 A.M. and given at 1:22 P.M. 29. Medical record review for Resident #42 revealed an admission date of 12/13/23. Medical diagnoses included PVD, obstructive uropathy, dementia, and respiratory failure. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #42 was to receive Ativan 0.5 mg twice a day, Albuterol Sulfate Inhalation Nebulizer Solution 2.5 mg/3 ml to inhale orally four times a day, Duloxetine HCI 60 mg once a day, Plavix 75 mg once a day, Lisinopril 10 mg once a day, Pentoxifyline ER 400 mg once a day, Apixaban 5 mg twice a day. The first dose of the medication was ordered for 8:00 A.M. and given at 10:44 A.M. 30. Medical record review for Resident #43 revealed an admission date of 03/05/24. Medical diagnoses included CVA, DM, renal insufficiency, and Alzheimer's. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #43 was to receive Glargine Insulin to inject 45 units subcutaneously in the morning was ordered for 8:00 A.M. and was given at 9:51 A.M. 31. Medical record review for Resident #45 revealed an admission date of 01/16/24. Medical diagnoses included DM and dementia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #45 was to receive Losartan Potassium 100 mg once daily. Aspirin 81 mg daily, Metformin 1,000 mg twice a day, Plavix 75 mg in the morning, Zoloft 25 mg once a day, Sodium Chloride 1 gram three times a day, Rosuvastatin Calcium 20 mg every morning, Carvedilol 3.125 once a day, Medroxyprogesterone Acetate 5 mg daily, and Amlodipine Besylate 5 mg once a day, were scheduled at 9:00 A.M. and given at 1:10 P.M. 32. Medical record review for Resident #46 revealed an admission date of 12/29/22. Medical diagnoses included CAD and seizure disorder. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #46 was to receive Keppra 500 mg one two times a day was scheduled for 8:00 A.M. and given at 10:55 A.M. 33. Medical record review for Resident #48 revealed an admission date of 01/12/24. Medical diagnoses included renal insufficiency, DM, manic depression, and schizophrenia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #48 was to receive Cephalexin 500 mg three times a day for five days, Pilocarpine HCI 7.5 mg three times a day, Ropinirole HCI 0/25 three times a day, Metoprolol 25 mg two times a day, Cliostazol 100 mg two times a day, Aspirin 81 mg once a day, Neurontin 100 mg two twice a day, Midodrine HCI 5 mg one three times a day, Zoloft 25 mg once a day, Omeprazole 20 mg once a day, Xarelto 15 once a day, Torsemide 20 g once a day, and Zyrtec HCI 10 mg once a day. The first dose of these medications was ordered for 8:00 A.M. and given at 11:49 A.M. 34. Medical record review for Resident #50 revealed an admission date of 12/29/22. Medical diagnoses included neurogenic bladder, paraplegic, and Multiple Sclerosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 12 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #50 was to receive Baclofen 10 mg three times a day and was ordered for the first dose at 8:00 A.M. and was given at 1:08 P.M. 35. Medical record review for Resident #51 revealed an admission date of 10/05/24. Medical diagnoses included NTBI, renal insufficiency, DM, and dementia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #51 was to receive Insulin Glargine to inject 15 units subcutaneously two times a day, Humalog sliding scale subcutaneously with meals, Metoprolol ER 25 mg once a day, Metformin 500 mg twice a day, Duloxetine 60 mg and 30 mg once a day, Aspirin 81 mg once a day, Lilostazol 50 mg twice a day, and Lisinopril 2.5 mg once a day. The first dose of were scheduled for 8:00 A.M. and given at 12:46 P.M. 36. Medical record review for Resident #52 revealed an admission date of 09/19/24. Medical diagnoses included PVD, renal insufficiency, septicemia, and DM. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #52 was to receive Empaglifloxin 10 mg once a day, Aspirin 81 mg once a day, Doxazosin Mesylate 500 mg one twice a day, Hydralazine 100 mg one three times a day, Losartan Potassium-HCTZ 50-12-5 mg once a day, Elliquis 5 mg one twice a day, Xanax 0.5 mg one twice a day, Insulin Lispro Injection eight units subcutaneously with meals, were scheduled for 8:00 A.M. and was given at 10:27 A.M. Interview with Resident #52 on 03/20/25 at 11:29 A.M. revealed her medications were late on occasionally, but didn't know the dates. 37. Medical record review for Resident #53 revealed an admission date of 01/04/23. Medical diagnoses included deep vein thrombosis (DVT), DM, and seizure disorder. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #53 was to receive Elliquis 5 mg one twice a day, Lisinopril 5 mg one once a day, Lasix 20 mg once a day, Carbemazepine 200 mg one twice a day, Clonidine 0.1 mg one twice a day, Clonazepam 0.5 mg one three times a day, Risperdal 1 mg one twice a day, Seroquel 100 mg one twice a day, Paroxetine 30 mg HCI one daily, Icosapent Ethyl 1 gram once a day, were scheduled at 8:00 A.M. and was given at 10:05 A.M. 38. Medical record review for Resident #54 revealed an admission date of 01/26/25. Medical diagnoses included cerebral palsy, HTN, and Schizophrenia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #54 was to receive Vraylar 3 mg once a day, Citalopram 10 mg three to be given once a day, Hydralazine HCI 10 mg one four times day, Potassium Chloride ER 20 MEQ's one time a day, Metoprolol 12.5 mg one two times a day, Clonidine HCI 0.1 mg twice a day, Torsemide 20 mg one twice a day were scheduled for 8:00 A.M. and given at 11:11 A.M. 39. Medical record review for Resident #55 revealed an admission date of 02/15/25. Medical diagnoses included CAD, DVT, HTN, renal insufficiency, and CVA. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #55 was to receive Metoprolol ER 25 mg one a day, Aspirin 81 mg once a day, Metolazone 2.5 mg one time a day, Torsemide 100 mg one twice a day, Elliquis 2.5 mg one twice a day was scheduled at 8:00 A.M. and given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 13 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 at 11:03 A.M. Level of Harm - Minimal harm or potential for actual harm 40. Medical record review for Resident #56 revealed an admission date of 01/01/25. Medical diagnoses included CAD, heart failure, renal insufficiency, obstructive uropathy, and DM. Residents Affected - Some Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #56 was to receive Carvedilol 12.5 mg one twice a day, Methocarbamol 500 mg one four times a day were scheduled for 8:00 A.M. and given at 10:58 A.M. 41. Medical record review for Resident #57 revealed an admission date of 10/03/23. Medical diagnoses included neurogenic bladder, septicemia, DM, CVA, dementia, and aphasic. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #57 was to receive Elliquis 5 mg one two times a day, Venlafaxine 50 mg one twice a day, Aspirin 81 mg once a day, Omeprazole 20 mg once a day, Metoprolol 25 mg one twice a day, Januvia 25 mg one a day were scheduled for 8:00 A.M. and given at 1:02 P.M. All of these medications were ordered through the g-tube. 42. Medical record review for Resident #58 revealed an admission date of 01/13/23. Medical diagnoses included NTBI, CAD, PVD, PNA, and dementia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #58 was to receive Lisinopril 2.5 mg one in the morning, Zyrtec once time a day, Rosuvasistatin 40 mg one once a day, Amlodipine 5 mg one once a day, Lasix 40 mg one once a day, Galantamine Hydrobromide 8 mg one once a day, Metoprolol ER 25 mg 12.5 mg once a day, were scheduled for 8:00 A.M. and given at 11:55 A.M. 43. Medical record review for Resident #60 revealed an admission date of 01/13/23. Medical diagnoses included DM HTN, and schizophrenia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #60 was to receive Humalog inject 18 nits subcutaneously before meals, Clonidine HCI 0.1 mg one once a day, Amlodipine 5 mg one once a day, Allopurinol 100 mg two once a day, Tizanidine HCI 2 mg one three times a day, Depakote 250 mg one twice a day, Gabapentin 100 mg two twice a day, Venlafaxine HCI 50 mg one once a day, were scheduled for 8:00 A.M. and given at 10:49 A.M. 44. Medical record review for Resident #62 revealed an admission date of 01/15/25. Medical diagnoses included HTN, DM and schizophrenia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #62 was to receive Depakote 125 mg twice a day, Vraylar 6 mg once a day, Venlafaxine HCI 75 mg once a day, Metformin 500 mg one twice a day, Humalog Insulin Pen sliding scale, were scheduled for 8:00 A.M. and given at 11:03 A.M. 45. Medical record review for Resident #63 revealed an admission date of 03/05/25. Medical diagnoses included wasn't any. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #63 was to receive Isosorbide Mononitrate ER 30 mg one once a day, Plavix 75 mg one once a day, Pantoprazole Sodium 40 mg one once a day, Tamsulosin HCI 0.4 mg once a day, Aspirin 81 mg one once a day, Coreg 25 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 14 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm one twice a day, Empaglifloxin 10 mg once a day, Atorvastatin Calcium 80 mg one once a day, Amlodipine Besylate one once a day, scheduled at 8:00 A.M. and was given at 11:01 A.M. 46. Medical record review for Resident #65 revealed an admission date of 01/13/23. Medical diagnoses included PVD, seizure disorder, schizophrenia, post-traumatic stress disorder, and respiratory failure. Residents Affected - Some Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #65 was to receive Potassium Chloride 20 MEQ one once a day, Buprenorphine Transdermal Patch 5 mcg/hour one time a day for seven days, Ultram 50 mg one every four hours, Lasix 20 mg take one once a day, Dilantin Oral Suspension 125 mg/5 ml 8 ml twice a day, Lactulose 10 gm/15 ml to 15 ml two times a day, were scheduled for 8:00 A.M. and given at 11:56 A.M. Interview with Resident #65 on 03/19/25 at 1:11 P.M. revealed he was supposed to get his medication at 8:00 A.M. and it keeps getting later and later that he receives them. He reported his medications were given to him today at 11:30 A.M. he stated if it is the regular nurses who work he got them on time, but if it were agency nurses they were late. 47. Medical record review for Resident #67 revealed an admission date of 05/13/24. Medical diagnoses included renal insufficiency, DM and depression. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #67 was to receive Depakote 250 mg to be given one twice a day, was scheduled for 8:00 A.M. and given at 11:02 A.M. 48. Medical record review for Resident #68 revealed an admission date of 04/19/24. Medical diagnoses included obstructive uropathy disorder, hip fracture, septicemia, and DM. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #68 was to receive Humalog Injection Solution sliding scale was scheduled at 8:00 A.M. and given at 11:04 A.M. 49. Medical record review for Resident #69 revealed an admission date of 09/22/23. Medical diagnoses included CAD, heart failure, HTN, DM and dementia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #69 was to receive Omeprazole 20 mg once a day, Atorvastatin Calcium 80 mg once a day, Aspirin 81 mg once a day, Midodrine HCI 5 mg twice a day, Finasteride 5 mg once a day, Tolterodine Tartrate 2 mg once a day were scheduled for 8:00 A.M. and given at 1:07 P.M. 50. Medical record review for Resident #70 revealed an admission date of 01/16/24. Medical diagnoses included DVT, and seizure disorder. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #70 was to receive Potassium Chloride ER 20 MEQ once a day, Lasix 40 mg once a day, Sertraline HCI 50 mg once a day were scheduled at 8:00 A.M. and given at 9:56 A.M. Interview with Resident #70 on 03/19/25 at 10:10 A.M. revealed she received her medications late at times and didn't know why. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 15 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 51. Medical record review for Resident #72 revealed an admission date of 02/04/25. Medical diagnoses included BPH and dementia. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #72 was to receive Lisinopril 2.5 mg once a day, Carvedilol 3.125 mg every twelve hours, Aspirin 81 mg once a day were scheduled for 8:00 A.M. and was given at 1:20 P.M. Review of the schedule dated 03/19/25 revealed there were three nurses scheduled, two being from agency and one from the facility. The schedule reflected the two agency nurses called off and the other nurse came in at 7:45 A.M. Interview and observation of the computer screen with Licensed Practical Nurse (LPN) #144 on 03/19/25 at 11:11 A.M., revealed she had medications pulled up for the residents and they were red indicating they were late to administer. The LPN reported she was late with her medications because there weren't any nurses in the building at 7:00 A.M. and she got called into work. Interview and observation of the computer screen with agency LPN #202 on 03/19/25 at 11:51 A.M., revealed he arrived at the facility at 9:20 A.M. because he signed up for a shift at the facility. He stated he didn't know the facility had opened until this morning. He reported he was late with his medications and his computer screen was red which indicated the medications for the residents were late. Interview with the Director of Nursing (DON) on 03/19/25 at 2:10 P.M., confirmed that the residents didn't get their medications until late, and the physician was notified and approved they were late. She reported there were two agency nurses who called off for 03/19/25 and when that happens no one in the facility knows they weren't coming, because the agency sends an email at 5:00 A.M. and no one looks at their email that early. She confirmed there weren't enough nurses this A.M. because their regular nurse was scheduled to come in at 7:00 A.M. and didn't arrive until 7:45 A.M. and confirmed this was why the medications were late. She stated she was off on 03/17/25 and the same thing happened because they had some call-offs from agency and didn't catch it till later, which made the medications late on some halls. Review of the policy titled Administering Medications, dated 2001, revealed medications are administered in accordance with prescribed orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specific (for example, before and after meal orders). This deficiency represents non-compliance investigated under Master Complaint Number OH00163298 and Complaint Number OH00163144. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 16 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure Infection Control practices were followed during a pressure ulcer dressing change. This affected one (#18) of three residents reviewed for infection control with pressure sores. This census was 71. Residents Affected - Few Findings included: Medical record review for Resident #18 revealed an admission date of 07/02/24. Medical diagnoses included coronary artery disease, heart failure, hypertension, renal insufficiency, diabetes and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility and transfers. He was always incontinent with his bladder and had an ostomy. Observation of a dressing change for Resident #18, on 03/19/25 at 9:25 A.M., with Licensed Practical Nurse (LPN) #144, revealed Resident #18 had a sign on the door indicating he was in Enhanced Barrier Precaution (EPB) isolation. LPN #144 washed her hands and applied gloves to her hands, but didn't place a gown on. She removed the dressing and discovered she forgot something for the dressing change and left the room. She came back and did not don a gown, regloved both of her hands and cleaned the wound, applied the packing into the wound and placed the dressing to the wound and then removed her gloves. Interview with the LPN #144 on 03/19/25 at 9:32 A.M., revealed LPN #144 wasn't aware the resident was in the EPB isolation and confirmed she didn't don a gown. She confirmed she didn't change her gloves from dirty to clean and didn't wash her hands either. Review of the policy titled, Enhanced Barrier Precautions dated 03/01/24 revealed the following: 1. Enhanced barrier precautions (EBP's) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms {MDRO's) to residents. 2. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed: to before entering the room). b. Personal protective equipment {PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: wounds. Review of policy titled, Wound Care dated 2001, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 17 of 18 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 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Steps in the Procedure Level of Harm - Minimal harm or potential for actual harm 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. Residents Affected - Few 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 12. Remove dry gauze. Apply treatments as indicated. 13. Wash and dry your hands thoroughly. This deficiency represents non-compliance investigated under Master Complaint Number OH00163298 and Complaint Number OH00163144. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366236 If continuation sheet Page 18 of 18